Announcement made that private rooms at the hospital are coming back
By Mary Alice Murphy
The monthly Gila Regional Medical Center Board of Trustees meeting, which was held April 27, 2018, usually begins with a safety moment.
Trustee Tony Trujillo announced that Gila Regional had recently received from Leapfrog an A rating because of safety. It's one of three A ratings in New Mexico, with the other two being Plains Hospital in Clovis and Lovelace in Roswell.
"Gila Regional also got a 4-Star rating from the Centers for Medicare and Medicaid," Chief Executive Officer Richard Stokes said. "Leapfrog was formed at the request of industry, so we are getting quality ratings from government and industry."
Trustee Mike Morones, who was chairing the meeting in the absence of Chairman Jeremiah Garcia, said the hospital had just finished meeting with the Joint Commission. "There is a big movement toward zero harm. What we learned from the Joint Commission was that hospitals are working toward quality in safety. From day 1, with (Chief Executive Officer) Taffy Arias, safety has been important."
Trujillo said the Quality Improvement Committee spends a lot of time discussing safety.
The hospital recognized Mario Ogas for his 20 years of service in security.
"It's hard to convey how impressive the longevity of staff's service to this hospital is," Morones said.
During public input, County Commission Chairman Billy Billings said he was speaking for himself, not in an official capacity. "I thank the Trustees for the selfless unpaid service to the community. Taffy was at our Commission meeting. She heard that we have a tough decision. The staff and employees are making the decision easy for me."
He said Dr. Nwachuku told him that the commissioners and trustees need to communicate more. "Mike and I have had a conversation on that issue. For me, it needs to start from our side. I look to a new relationship going forward."
A new aspect of each meeting is board input, giving the board members a chance to talk and dialogue together. "We don't always communicate with other trustees," Morones said. "That's why I put it on the agenda to start a dialogue."
He congratulated staff for the Leapfrog A rating, the successful Joint Commission visit, maintaining the 4-Star rating and receiving the recent top 100 rural hospitals in the country recognition.
"We must educate ourselves, verifying what we are told, monitoring and giving better oversight," he said.
Trustee Dr. Tsering Sherpa said she had served on the board at Lea Hospital. "It was a formality. I was naïve. This board is more responsible. I have learned more about how a hospital works. My heart is in this hospital. It's one of the reasons I joined this board. This hospital is a gem. I want to keep learning and helping how I can."
Trustee Joel Schram commended Ben Fisher for his article where he made a comparison to things that happened back East with a hospital being acquired. "I was a trustee at that hospital. I left in 2005 when they were in the process of getting rid of Quorum. We weren't in financial trouble, but we wanted to do some other things. We want this hospital to stay in the community."
Trujillo said he is in his fourth year on the board. "I have learned a ton. Health care is a tough world to be in. I think we got ourselves in this situation because of a lack of communication. We should never lose sight of being appointed by the commissioners. We have the statutory responsibility to be in charge of operations, but the Commission owns the hospital and has the authority to make decisions. I thought comments last night overall were positive (at the community meeting hosted by the Grant County Commission, which can be read at http://www.grantcountybeat.com/news/news-articles/43948-grant-county-commission-holds-community-forum-on-grmc-042618 ). We owe it to the hospital to tell our story to the community. A long time ago, we used to do a state of the hospital presentation to tell our story. We need to talk to the community about where we are, where we're going and how we are attacking challenges. The commissioners are in the phase of getting proposals. The sooner they end the process, the better for our employees."
Trustee Jeannie Miller read her comments that she had written out. "I attended all three meetings—the one with the physicians, the one with Gila Regional staff and last night's meeting. I want to speak about accountability. We stated clearly that we are accountable for this hospital. We have fiduciary responsibility, which we took when we assumed board positions. With our presentation to the commissioners, we became a suitor."
She said, as she understood it, the Juniper Advisory project was about the financial situation. "This hospital is an organic system. We have no silos in this hospital. Given this ecosystem, it is not a trivial undertaking. We are committing to doing due diligence and are committed to the excellence of this hospital. We have a leadership team that understands rural health care. As an analogy: we are like the little engine that could and did. We are the little hospital and we are here to do our job."
Morones said when he was on the Town Council, they used to have councilor comments on issues. "We want to communicate with the other trustees and the community, in the same way."
Chief of Staff Dr. Gregory Koury, a non-voting member of the Board of Trustees, said: "We did call a general medical staff meeting. Twenty-three, including three residents from Hidalgo Medical Services, attended. Only five who are active in this hospital were not there. Our medical staff overwhelmingly wants to keep the hospital county-owned. They felt confident in the administration and want to build on the plans that are being put forth. Only we can take care of patients in the best way."
In reports, Frances Day gave the Gila Regional Auxiliary report. "We love the hospital, too. It's why we have volunteers. We love the community and the hospital. We had a really good District meeting here. Members of the New Mexico Hospital Association attended. I want to give a shout out to the culinary department. We had a High Tea, with a modern emphasis on an old tradition."
To a question, Day said the Auxiliary has 64 regular members and 11 associate members. "We put in 1,282 hours the past month. Last year we gave $90,000 to the hospital and $22,000 to scholarships. We put in around $6,000 to $7,000 a year for meals for cancer patients. We do a lot that is not seen."
Morones said not only the Auxiliary gives money to the hospital, but so does the Foundation. "Most private corporations don't have an Auxiliary and Foundation. We forget to tell that story."
Billings, who also serves on the Foundation, thanked First American Bank for being the sponsor for the June 9 golf tournament. "I appreciate the new hospital leadership relationship with the Foundation."
Morones noted that for 18 months, the Foundation had been forgotten by the hospital. "It almost went under. We have other opportunities that are not being discussed that are available to us."
Arias presented her CEO report. "I want to highlight the expanding footprints of our clinics. We will have one in Deming with four to five physicians and specialists. We are also looking at other locations."
She said Gila Regional extended an offer to an ENT (ear, nose and throat specialist), and he is working on his New Mexico license.
"In oncology, we are continuing to see more patients," Arias said. "We extended an offer to a full-time oncologist. UNM, which will be the oncologist's employer, counter offered and we should hear soon. The PET scan starts up on Monday, April 30, and radiation is scheduled to start May 2."
Miller asked about the Cancer Support Group. "I saw a news release on the Beat. I suggest we also get these releases on the radio calendars. There are a lot of other online calendars in the community."
Chief Nursing Officer Peggy White said she had no highlights. Miller asked if when the hospital starts on the post-discharge follow-up, would it include inpatient and outpatient clients.
"Currently, we're mostly doing outpatients, but we are getting more aggressive on following up with inpatients, too," White replied. "When a patient comes into the hospital we give them a status and continue to follow up twice a day to make sure the same status is in place. It's part of our evidence-based system of control."
Stokes said it is critical to determine the status. "If we have them marked incorrectly as inpatient and they are just there on observation status, we have to correct. There is a lot of work to connect."
"This coming Monday, we will be admitting patients to private rooms," White said.
Arias said the rooms have not been decorated. "We want to make sure that the private rooms are active as soon as possible. It costs money to change things, so we want to work out the bugs before spending the money."
"Because they are basically double rooms, we will set one side as the patient side and the other part for family," White said.
Trujillo asked how many traveling nurses are in the hospital at present.
"More than I want," White said. "As soon as Tanya Carraccio (chief quality officer) comes back, we will revamp the residencies for nurses and bring the program back. By the end of May, we will have 11 travelers."
Stokes said the residency program is for the new nurse who has the academic knowledge, but not the practical knowledge. "They will serve under a precept."
White said when the hospital had the residency program before, it became a model. "But our own program went away."
Arias noted that often the CFO sits in an office and is called the CFNo. "The more the CFO is involved in the clinical side, the better for the hospital. Richard has engaged himself in programs."
White said he is the only one of the five CFOs she has served under who "has sat with me and discussed clinical issues."
Morones said that highlights why Stokes has been so successful so quickly. "We have some of our Trustees do rounds, too, and see staff. It's important. The CFO is better understanding what's happening at the staff level. I don't understand what the staff goes through. I look forward to knowing what's going on."
White said directly above their heads, "life is entering this world (in labor and delivery); 30 yards to the east, life is leaving this world (from the ICU)."
Stokes presented his report. "I am continuing the new format. March is the ninth month of the fiscal year." He commented that what he reports in the monthly board meeting is about 90 percent to 95 percent of what he says in the Finance Committee meetings. "The variances are that I give more details in the Finance Committee."
"Another comment I would like to make is that in the past two months, we have posted really good numbers," Stokes said. "I want the board and the community to understand that there will be months that are not as kind."
For March, "we had $6.8 million in revenue, with $5.5 million operating expenses. The bottom line was $818,908. We had budgeted to lose $103,000, so we had a more than $922,000 swing, which was good. Year-to date we have a loss of $339,674, and had budgeted to be up by $500,000, so we missed budget. However, to date last year at this same time, we had a loss of $289,000, but at the end of the fiscal year, we lost $6,295,640. With the current loss of $339,674, we have a $5,956,000 swing to the good."
"I wish I could claim part of that, but Taffy came in and she and JoBeth (Vance, interim CFO) laid the foundation," Stokes said. "They did this. It is unheard of for a hospital to swing that far that fast while we continue to improve quality. There is a correlation between finances and quality. Without quality, we can't grow. The building blocks to grow are there."
Trujillo asked how Stokes would have addressed the $22 million loss over the past six years, as mentioned in the meeting of the commissioners and the community the previous evening.
"We obviously funded it out of cash," Stokes said. "One lady raised a good question. Say we make $10 million and we hope to be close to that, or even $5 million, if the profits don't stay locally, if the money goes out to another entity, we don't get the local multiplier effect. Obviously, such large losses cannot continue. Taxpayer dollars assisted with those losses."
Trujillo said: "We keep saying we're debt free and that's important because it helps us weather the swings. This hospital is well positioned to handle ups and downs of financing as we were experiencing. We’re past that and looking ahead."
Stokes said the hospital has been getting feedback from staff in townhalls. "The time to plan for the bad is when it's really good. We're getting traction on our plans now. Last month we talked about the 1115 waiver. On April 17, we got a check for $6,264,146. Of that $2.8 million was for uncompensated care in 2016. It also included the 2017 $285,000 quality payment and the first quarter in uncompensated care for 2018 of $2.158 million. We will get another $2.158 million in July and the following two quarters."
He talked about HRG, which is the consultant the hospital has contracted with for billing and to help Gila Regional correct the upstream process. "They began April 19 and have identified other issues, too. We are confirming the potential $4.5 million number, which should be a good number. That's going very well, getting ramped up and hard at work."
"I also want to give you an update on the Navin-Haffty consulting firm for Meditech," Stokes said. "They will do a revenue cycle assessment just on the Meditech system. They have worked on the medical dictionary and will spend a couple of more weeks on corrections and optimization and then will start on the business office dictionaries, where there are significant issues and will take a bit longer. I asked Dr. Koury to have Kari (Lane) to get with the physicians to get their three top issues with Meditech. We will target at least one over the next 30 days and get it fixed."
Stokes said next month the board will get an 8-page revenue cycle report. "I will break it down by payor and AR (accounts receivable). It will be a comprehensive report with clean pay rate and denials. We have to extract from Meditech back to last June, so we can trend what's happened. This will be the benchmark from last June. I'm well aware of the need for employee compensation as well as building and equipment needs, but we can't make good decisions without knowing the trend."
Miller asked: "When we say we are a $71 million hospital is that what we bill?"
Stokes said the $71 million is gross revenue, "but we have contractual adjustments. Net revenue is what I expect to turn into cash. There is no need for department heads to see gross revenue because they can't control it, but they can control how many scans, how many MRIs they do. That's their customer. They have to build relationships with physicians, so the physicians send their patients there."
"So, what we see in the reports is what we expect?" Miller asked.
"Yes, because I have to manage net revenues," Stokes said.
He continued with March statistics. "We had 195 inpatient admissions as compared to 183 last year. We budgeted for 191. This March, we had 573 patient days as compared to 616 last year."
Schram said: "It's really good to roll them out quicker, because we get better reimbursement."
"We're not expected to hang on to patients, so we don't," Stokes said. "We don't kick them out, but my philosophy is the longer a patient stays, the better the chance to get something else. Hospitals are dangerous places. The average length of stay was 2.9 in March. Last year was 3.4 days. In the ER we had 1330, with last year 1575. I'm not satisfied with the ER trend. We need to look at it, but I think it's because prople have other options. We had 3600 outpatients, which was slightly below budget. For the clinics, they had 1623 visits. We missed the budget bad, but I don't see any one bad issue on the clinical practices. We still have opportunities to increase that. Surgeries were 350, with last year at 405. But last month we were up, so it fluctuates. In oncology, we had 252, compared to last year's 739, but we're still ramping up. I expect that to change this month and next."
The key performance indicators (KPIs) showed cash of $4.696 million compared to $4.68 million last year, "so we collected $16,000 more. We had a dip in births, but more last month, so it varies. Days cash on hand at the end of March were 39, but Alfredo (Pacheco, controller) and I drove it down paying AR (accounts receivable) because we knew we would get a payment in April. It's up to about 73 days of cash on hand today. Our daily expenses dropped to $181,000 from $203,000 last year. This year we had $532,000 daily revenue, as compared to $644,000 last year."
He commented on the report by the commissioners about the $22 million lost over six years. "The Cancer Center was going wide open during that time. When we lost the sole community provider, that hurt us by $10 million a year."
Stokes said the case mix index stands at 1.41, which indicates severity of illness. "For our size hospital, I would like to see the case mix index above 2."
"Next month, I will add an additional KPI, with the average daily collections," Stokes continued. "We need to watch that number."
He said he also plans to add a look ahead, so the board "knows where we are headed for this month, not just looking at old data, but what this month looks like."
Morones noted that the days in net AR are at 64, but in AP (accounts payable), they are 53. "We are working to get those numbers closer, so we're not paying out more than we are receiving. We try to get vendors paid in a timely manner. It's important because many of the vendors are local."
Miller said she understands that last year's budget process was kind of thrown together, because Taffy had just come in, so "I think for trends, it is probably better to look at the prior year. I hope this year the budget makes more sense."
Stokes said Pacheco is basing the budget on drivers. "We are a complex organization. We can do the budget on Excel, but we'll be looking for a better system next year. I don't like doing one static budget once a year. I prefer to prepare a rolling budget, so we have a higher level of control than we are capable of today, but we'll get there."
Historically, the budget was done to comply with state regulations, Morones said. "But the budget is an important tool for management to watch their progress. It's also a good part of our oversight, if we have a budget we can monitor."
Chief of Staff Dr. Gregory Koury said at the medical staff meeting, "we asked for staff raises, a clothing stipend and bonuses. We did a report. We also wanted to do a presentation to the General Medical Staff."
Trujillo said: "When we do a state of the hospital, we should include you."
Koury said the Joint Commission had a couple of issues with the bylaws, but "other than that, a couple of physicians presented to the Joint Commission and it went well."
Under Board Committee reports, Morones said the Executive Committee approved the agenda.
Trujillo for the Quality Improvement Committee said they had decided the safety moment should always be part of their agenda. "We're working on a lot of the benchmarks. How's the survey coming?"
"We haven't begun it yet," White said. "When Tanya is back, we will get on it. Internal surveys are going on in nursing."
Sherpa noted that one of the items the hospital is marked low on is quietness. White said that would be improved by single rooms.
Morones gave the Finance Committee report and asked for approval from the Board for two contracts. One was for a one-year-extension to June 17, 2020, to an agreement with Dr. Ronald Dalton for pediatric services, chief medical officer and call coverage. The second was a professional services agreement for Gila Multispecialty Independent Physicians Association. "We pay them to administer the on-call services. They find a doctor to do on-call services in the ER or Obstetrics, for instance.
The Plant and Facility Committee, Schram said, identified items in the Behavioral Health Unit. They included room configurations and fixtures with which patients could potentially harm themselves. "We are also addressing the overhead code announcements and developing a card to attach to badges."
Miller noted some IT people had left. Schram confirmed the IT department is about one-third staffed. Morones noted the overhead code issue came out of a safety moment.
Trujillo gave the Human Resources Committee report. "We mostly went through the dashboard. The 627 employees include 430 full-time employees. We spent time on turnover statistics. Sixteen people left. We looked at areas, such as housekeeping, which is a big area where they are leaving. It costs about $35,000 to train new employees. We looked at overtime and at contract employees, which is high again for March, but there are reasons behind it."
Morones said the hospital does exit interviews. "Sometimes, they are frank. There aren't any punitive effects for what they say. They can come back, right?"
White said their treatment if they want to come back is based on their history, not on the exit interviews.
Trujillo said it's tough to get people to do exit interviews. "We asked staff to create a policy, such as if they have company property, they must turn it in before their last check."
Schram said it was discussed in the QIC meeting that when situations arise where the department could be short on nurses, the directors have stepped in. "Here they are part of the hospital."
Stokes noted that some hospital directors at other venues do not do that.
The Trustees, after a 15-minute break, went into executive session for routine items.