SOUTHWEST HEALTH SYSTEM, INC.

SOUTHWEST MEMORIAL HOSPITAL

BOARD OF DIRECTORS MEETING

 

Date:     July 23, 2003                                                                                                                                                                              

 

Present:                                                                 Also Present:                                                                                                        Roles:

Charles Hubbard, Chairperson

Bob Peterson, CEO

 

Leader:                Charles Hubbard

Joan Luhman, Vice-Chairperson

Mike Anderson, Interim CFO

Lisa LaPlante, Admin. Nursing Assist.

Timekeeper:         Joan Luhman

Susan Hatter, Secretary/Treasurer

Dianna Fury, M.D., Medical Director

Lionel Montoya, Accounting

Facilitator:            Don Lipari    

Terri Forth, Director

John Petty, M.D. Chief of Staff

Anne Schuenemeyer, Director Med/Surg

Recorder:              Jan Saunders

Jim Hanosh, M. D., Director

Kyle Cruzan, OR Director

Tye Sprague, Coordinator FBC

 

Bruce Johnson,  Director

Stephen Day, IS Director

Vonnie Tanner, Coordinator FBC

 

Don Lipari, Director

John Greenemeier, Foundation Director

Duane Neal, Chairman, MCHD Board

 

Chuck McAfee, Director

Kathy Greenlee, CNO

Kent Williamson, Attorney

 

Spencer Smith, Director

Janet Knisley, Director ICU

Jan Saunders, Executive Assistant

 

 

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

Call to order

Charles Hubbard called the meeting to order at 6:00 p.m.

 

 

Public Comment

There was none.

 

 

Board Education

Kathy Greenlee, CNO, has been a nurse for 34 years and at SWMH for 30 years. She started as a pediatric nurse, worked in the OR, and has worked in all departments, but really likes obstetrics. She has almost completed her BSN.

She has a really good team of leaders in OB: Jamie Ritthaler, Tye Sprague, and Vonnie Tanner are OB Coordinators.

 

After giving the Board her background, she then

gave a presentation on the changes that are happening in nursing at SWMH:

  • Mesa State College may be bringing their nursing program for BSN to SWMH
  • Revised staffing matrix on Med/Surg
  • Continuing to monitor indicators for patient outcomes
  • Nursing Administration resolution request form to replace Question/Answer form

 

 

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

Board Education

(continued)

  • Clinical meetings to be mainly scheduled on Wednesdays
  • There are no regularly scheduled staff meetings with nursing administration
  • When they went to a new matrix, they went from 8 to 12 hours
  • This year she is going to meet quarterly with all nursing
  • Minutes include resolved/unresolved issues list
  • CFO is having monthly financial meetings with nursing managers
  • Monthly meetings to review MOR’s
  • New employee meetings with CNO
  • Survival packs given to new staff
  • Chart reviews that are diagnosis/problem specific
  • Redesigning documentation
  • Reassessing non-clinical roles of clinical staff
  • Investigating flex scheduling
  • Investigating patient placement
  • Forming a Geriatric Committee
  • Now have a mentorship program
  • Have an LPN program
  • Nursing policies are available on the Intranet
  • Nursing leadership minutes are available on the Intranet
  • Team nursing
  • House supervisor position
  • Salary model
  • Rewarding existing staff who recruit new employees
  • Clinical ladders
  • Physician survey (nursing)
  • Nursing survey
  • Pediatric team
  • Policies and procedures
  • Recruitment and retention

 

 

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

Board Education

(continued)

·       Medical staff driven: patient care and pharmacy and therapeutics

·       Interdisciplinary nature of nursing department

 

 

Report by MCHD Chairman

·       Duane Neal, MCHD Chairman, and Charles Hubbard, SHS Chairperson, have agreed to have a monthly luncheon.

·       The TEFRA hearing went smoothly due to all the work that preceded it.

·       We are getting closer to the $10 million loan.

·       At a meeting the other day, the MCHD Board discussed the PUD and a new street name.

·       MCHD has agreed to purchase the property on the south side of Dr. Heyl's property and to straighten out the street.

·       At their meeting, the Board discussed the PUD covenants.

·       MCHD has been contacted again by Valley Inn as an option for the nursing home; feasibility study still on- going.

·       MCHD is excited about getting close to signing something for the building project.

·       FYI - there may be a segment of the population that wants to know how we are getting around TABOR.

 

 

Review Agenda

There was one information item added to the agenda.

 

 

Review of Minutes

(Enclosure 1)

 

 

 

 

 

 

 

Financial Notes for the Month of June 2003

(Enclosure 2)

 

·       The SHS Board of Directors reviewed the minutes of the SHS regular Board Meeting of June 25, 2003. Under "Medical Staff Credentials" add the verbiage, "As recommended by the Medical Executive Committee, a motion was made…" Also, on the motion to reappoint Kurt Rohren, M.D., to the Active Medical Staff, the "e" was left off of the word "one" in the last sentence.

 

There was no Finance Committee Meeting in June. However, the Interim CFO, Mike Anderson, presented a synopsis of the June financials:

 

A motion was made to approve the minutes of the SHS regular Board Meeting of June 25,2003, as corrected and amended. The motion was seconded and carried.

 

 

 

 

There was a motion to approve the financials as presented. The motion was seconded and carried.

 

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

Financial Notes for the Month of June 2003

(continued)

 

 

 

 

 

 

·       The key element for the month was that we were budgeted to lose $72,000, but instead made $64,000; the swing came from patient revenue.

·       Med/Surg was up due to patient days.

·       CT revenues were up $21,000.

·       Pharmacy was up $11,500, but that was driven by the price of drugs.

·       PT was up.

·       Outpatient revenues and Same Day Surgery were up.

·       Home Health was up.

·       Medical Imaging was up by $34,000.

·       Benefits were down.

·       Medical Specialty fees were up, driven by Anesthesia fees.

·       Purchased Services were on budget.

·       Supplies were slightly above budget.

·       Utilities were up due to a price increase that had not been anticipated during the budgeting process.

·       Repairs and maintenance were down.

·       Rentals and leases were up.

·       Insurance is about right on budget.

·       Bad debt expenses were down.

·       Cash on hand remains stable.

·       Ratios are between the 50th and 75th percentile.

·       Paying off the bond hurt the ratios, but they remain constant.

·       Had more Med/Surg days.

 

 

 

 

 

 

 

 

 

 

 

 

Quorum Management Report

(Enclosure 3)

 

·       Harry Jarvis from QHR was supposed to be here tonight, but got tied up interviewing CFO candidates.

·       QHR is interviewing 5 candidates for the CFO position; three are good, viable candidates.

·       It will be another month or two before we look at them. Bob will invite members of the Board to interview them.

 

 

Southwest Healthnet

(Enclosure 4)

This is for information only; there were no additions.

 

 

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

Board Calendar - August

(Enclosure 5)

Nothing further to add.

 

 

 

Revised Bylaws from June 25, 2003, Meeting

This is for information only; the changes voted in at the June 25, 2003, meeting are reflected in the Bylaws enclosed.

 

 

Scholarship Program

The Foundation Director, John Greenemeier, reported on the scholarship recipients:

  • The two new $600 scholarships for this year went to Morgan Ouellette and Alicia Mason.
  • Two repeat $600 scholarships have been awarded to Kristen Gustafson and Royanne Lichliter
  • A news article will be coming out in the paper next week informing the public about the scholarships and asking them to donate to the scholarship fund.
  • Since 1991, when the first scholarships were awarded by SWMH, 53 scholarships have been awarded totaling $31,800.
  • 28 people have received scholarships; some have received multi-year scholarships.
  • 4 people have received 4-year scholarships.

 

 

Special Meetings in Annex Community Room - MUST check ACR calendar first

The Annex Community Room schedule MUST be checked before Special Meetings of either Board are scheduled. The room is being highly utilized by the community, and there have been a couple of cases already where we have had to bump community organizations to accommodate Board meetings. We would like to minimize this happening.

 

 

TEFRA Meeting

As already reported by Duane Neal, the meeting went well.

 

 

Patient Call System

Responding to a Board member's concerns about the call light system, the following was discovered: When the new system was originally installed in February, the transmitters were not working. They have now been fixed, and the response times to patient calls can now be tracked.

 

 

Final Cost Estimate for Building and Renovation Project with 60% Drawings Completed

(Enclosure 7)

·       We are currently at a cost of $9,395,822 for the building renovation and expansion project, but are trying to pare off another $100,000.

 

 

 

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

Final Cost Estimate for Building and Renovation Project with 60% Drawings Completed

(continued)

·       We have ordered the steel and will order the dirt work at the July 30 meeting.

 

 

Customer Service Program

(Enclosure 8)

·       The Customer Service Program is off and running.

·       The kick-off was fun.

·       People are signing and returning the Customer Service Standards.

·       The goal is to have everyone trained by some time in August.

·       The program will make a difference in the hospital, not only in how we treat patients, but in how we treat each other -- and it's fun!

 

 

Additional Information Item

Dr. Karen Libsch is currently a Resident at SWMH who can do C-sections. We need to take her to dinner and convince her to stay on here after her residency. We need people who would be interested in taking her to dinner and convincing her to stay here.

Susan Hatter, Joan Luhman, Bruce Johnson, Chuck McAfee, Jim Hanosh, Terri Forth, Charles Hubbard, Dianna Fury, and Duane Neal all volunteered.

Jan Saunders will arrange.

Quality Council Minutes

(Enclosure 9)

The Quality Council Minutes for June were reviewed.

It was moved and seconded to accept the Quality Council Minutes for June as presented. The motion was seconded and carried.

 

Resolution regarding Enterprise Zones

(Enclosure 10)

John Greenemeier drew up a resolution regarding Enterprise Zones and updated the Board on his progress in getting this designation.

·       Both Montezuma and Dolores Counties have bought into this, which is a prerequisite.

·       John is meeting with Ed Morlan, Director - Region 9 Economic Development Council, Friday in Durango to present the resolution to him.

·       The resolution indicates that there is a need to reimburse providers who perform their healthcare service free-of-charge. (We hope to retain physicians by reimbursing them for this donated care.)

·       There is also a need to reward community members for donating to the Foundation.

 

A motion was made to accept the resolution on "Enterprise Zone Contribution Project" as presented. The motion was seconded and carried.

 

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

Resolution regarding Enterprise Zones

(continued)

 

·       After Region 9 approves the resolution, it will be forwarded to the State.

John Greenemeier went on to explain the hospital's and his involvement in the Montezuma/Dolores Community Summit Healthcare Committee.

·       The committee has put together a list of medically related services provided in our community -- 70 organizations.

·       This committee will develop a matrix to see if there are duplications or holes in the services provided.

·       Caring for Colorado, which provides significant funding for healthcare organizations, contacted the Community Summit and allowed them to put together a presentation last Tuesday night through a statewide teleconference.

·       In that presentation, John outlined the greatest unmet healthcare needs in our community, the budget cuts in our community, and how Caring for Colorado could help us in solving these problems.

·       The presentation went well, and a state agency wants to come down and visit with hospital representatives.

·       We may get financial assistance for the Community Summit, the hospital, and for healthcare-related organizations in our community.

 

 

PHO Representatives from SHS

(Enclosure 11)

·       The current PHO representatives from the hospital are Bob Peterson, Mike Anderson, Rhonda Van Dover, and 2 Board members -- Susan Hatter and John Greenemeier.

·       The commitment to be on the PHO Board is normally one monthly meeting which is held from 7:30 - 9:00 a.m. on a Monday morning.

·       The meetings deal with employer-owned groups with whom we have agreements and discounts.

·       We need to appoint one new Board member since John Greenemeier is no longer on the Board.

·       Susan Hatter said she would continue, but she may have to leave the meeting early for work.

A motion was made to reappoint Susan Hatter and to appoint Don Lipari to the PHO Board and to specifically name the CEO, CFO, and Compliance Officer as required members of the Board. The motion was seconded and carried.

Laura Rice

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

PHO Representatives from SHS

(continued)

 

·       Don Lipari volunteered to be the other Board representative.

 

 

Draft Covenants for MCHD PUD

(Enclosure 12)

·       Kelly McCabe drew up the draft covenants for the MCHD PUD.

·       MCHD's position was to make them pretty stringent -- they can always back out of them, but it is harder to tighten them up.

·       SHS attorney, Kent Williamson, had a couple of comments:

·       Page 2, paragraph # 3 regarding architectural control committee: it does not specify where the other two committee members come from.

·       Page 5, subsection ix regarding Medicare/Medicaid patients: Kent suggested that the language should not limit a physician's acceptance of Medicaid/Medicare patients. Putting in a percentage may prevent a physician from buying there. A physician must accept a reasonable number of Medicare/Medicaid patients based on the community average. He suggested the same verbiage be used as is in the Physician Recruitment Contract about having to "participate" in Medicare/Medicaid. He did not think it would be possible to enforce percentages.

A motion was made to support the MCHD PUD Draft covenants as presented and to look further at the two items in question. The motion was seconded and approved.

 

CER for Anesthesia machines

(Enclosure 13)

·       During the budget process, the anesthesiologists were asked if the anesthesia machines were all right, and they said they were.

·       Now they are breaking down, and one can't be fixed.

·       Our current machines are 7 and 9 years old.

·       After the building project, we will have three operating rooms, and we need 2 anesthesia machines.

·       The current request is to purchase one anesthesia machine now, unbudgeted, and we will buy the second one in January after the new capital budget comes out.

 

 

A motion was made to authorize the expenditure of $165,000 for one anesthesia machine to be purchased now. The motion was seconded and carried.

 

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

Insurance Renewal Costs and Coverage

(Enclosure 14)

·       The Board of Directors authorized the CEO to negotiate insurance renewal costs and to look at other carriers.

·       The enclosure is a summary of the renewal costs and coverage which the hospital now has.

·       We took out optional coverage for "non-certified terrorism," meaning that any type of terrorist attack on the hospital will be covered even though the person or organization is not a known terrorist or terrorist organization

A motion was made to approve the insurance renewal costs and coverages as summarized on the enclosed sheet. The motion was seconded and carried.

 

 

The Board took a break at 7:50 p.m.

 

 

 

The Board adjourned into Executive Session at 8:05 p.m.

 

 

 

The Board came out of Executive Session at 8:35 p.m.

 

 

Medical Staff Credentials

 

As recommended by the Medical Executive Committee, a motion was made to reappoint Terry R. Cook, DPM, to the Medical Associate Staff with clinical privileges in Podiatry as requested with the restriction as noted. The motion was seconded and carried. There was one abstention.

 

As recommended by the Medical Executive Committee, a motion was made to appoint Walter Patrick Haney, M.D., to the Provisional Active Medical Staff with clinical privileges in Diagnostic Radiology. The motion was seconded and carried. There was one abstention.

 

As recommended by the Medical Executive Committee, a motion was made to reappoint Alan F. Houston, M.D., to the Active Medical Staff with clinical

 

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

 

 

privileges in Emergency Medicine as requested, including the deletions and one addition. The motion was seconded and carried. There was one abstention.

 

As recommended by the Medical Executive Committee, a motion was made to reappoint Tracy Lippard, M.D., to the Active Medical Staff with clinical privileges in Internal Medicine as requested. The motion was seconded and carried. There was one abstention.

 

As recommended by the Medical Executive Committee, a motion was made to reappoint Jonathan Delacey, M.D., to the Active Medical Staff with clinical privileges in Diagnostic Radiology as requested. The motion was seconded and carried. There was one abstention.

 

Personnel Issues

 

A motion was made to have the CEO write a letter to Michael Woods, M.D., expressing our sincere interest in his locating to this area. The motion was seconded and carried. There was one abstention.

 

A Board member requested that the job description for Director, Strategic Quality Management/

Marketing be put in the parking lot.

Bob Peterson

 

 

 

 

 

 

 

Jan Saunders

Agenda Item/Topic

Findings and Discussions

Conclusions, Recommendations, Actions, and/or Motions

Follow-up Responsible Party

Parking Lot

1)     Invite the Board to any tabletop disaster drills, provide them a copy of the new emergency preparedness plan, and invite them to be victims in the next emergency preparedness drill.

2)     Human Resources monthly report regarding evaluations.

 

 

 

 

 

 

As this is a regular part of the QHR Report under Human Resources, this will be dropped from the parking lot.

 

 

The Board adjourned into Special Executive Session at 8:40 p.m.

 

 

Adjournment

The meeting adjourned at 10:15 p.m.

 

 

 

 

Respectfully submitted:

 

 

 

_____________________________                                     ________________________________

Susan Hatter, Secretary                                                                Charles Hubbard, Chairman