At least two recruits who were interested in positions at the hospital got tired of waiting to find out what the ultimate outcome of the Grant County Commission's decision will be.

By Mary Alice Murphy

The Gila Regional Medical Center Board of Trustees monthly meeting held on Friday, May 25, 2018, began with its customary safety moment.

Chief Quality Officer Tanya Carroccio said the hospital wants to continue to focus on staff safety, as well as patient safety.

Board Chairman Jeremiah Garcia agreed and said: "We have to protect our caregivers. We should never take anything for granted. It's important to protect everyone on our campus."

During board input, Trustee Jeannie Miller thanked the staff for a "great public forum. It would have been nice to have had more there, but we had a good turnout. I also want to congratulate Tanya on getting her doctorate. And I, for one, want to know as soon as possible, what's going to happen with the hospital and what the commissioners are going to do."

Trustee Tony Trujillo said he was unable to attend the public forum, but "I got excited by the feedback I got on the state of the hospital. We shouldn't have waited as long to have one. We should do one twice a year."

Garcia concurred. "I encourage the Board of Trustees to do town halls for the communities. I am challenging and encouraging the Board and the administrative team to choose dates and keep it going. Mr. (Richard) Stokes (Chief Financial Officer), you rock. You are talking to ordinary people about finances and they understand them. I got a lot of compliments on the ability of the CFO and the staff to deliver the message in an understandable way. That should be standard practice."

Trujillo reminded the members they owe the Grant County commissioners a response. "They want input from us on the selection process for trustees."

Garcia said it would be discussed in executive session. "Maybe we'll create a formal document."

Auxiliary President Frances Day announced the auxilians had delivered their 600th baby blanket to the hospital.

"I have some safety concerns, but don't know where I should address them," Day said.

Carroccio said they should come to her. Day said she would meet with her.

Day also introduced Jennifer Yost, Auxiliary president-elect, who will take over in July. "I'm glad to serve and I will be coming to these meetings. I've been in the Auxiliary four or five years," Yost said.

Chief Executive Officer Taffy Arias thanked Day for "everything you've done for the hospital."

"Jennifer has asked me to continue to serve on a couple of committees," Day said. "And I think I will work with the volunteers in the emergency room. We need some more help down there. We can always use more volunteers."

She said she would also be working on a 40-foot by 20-foot greenhouse that the slab is poured for at her house. "Over my past three years here, I have noticed how the atmosphere has changed. It has made me happy to see you laughing and joking. The amount of time you put in as volunteers, I think you are marvelous. We like working with you."

Arias began her CEO report with positive news. "We are looking at three potential sites in Deming for expansion of the family practice clinic. We are still looking for an additional family practice member, a nurse practitioner and two occupational therapists."

She said oncology is doing well, with the radiology service line opened. "It is going very well. We are fully staffed except for an assistant. Our recruit for an ENT has not yet gone through the processes for credentialing."

In the less than stellar news, she said the oncologist to whom they had made an offer was waiting to find out what the status of the hospital would be from the Grant County Commission. "He told us he couldn't wait any longer, and so, now he is looking for another position. Also, the urologist who really wanted to come and said ours was by far the best financial offer he had received, told us he couldn't wait any longer and is out looking for other positions to take care of his family."

"We interviewed a pediatrician, who, because of his current position, would not be available before October, but told us he really wants this type of work environment," Arias said. "We have a general surgeon coming to visit next week. He's from Egypt and does general surgery, as well as vascular and breast tissue conservation, which is minimally invasive practices."

The Joint Commission: Accreditation, Health Care, Certification (JCAHO) visit occurred April 17-19. "They gave us a 45-day window to address issues. We are working hard to rectify the issues, and we have almost everything completed," Arias said.

Stokes said the reason for not having yet completed everything was that the hospital is waiting for supplies to arrive.

Trujillo went back to the pediatrician and asked about buying his current position out. "I don't think his people would allow us to buy him out," Arias replied.

Miller asked about the oncology service line report. "What is the difference between treatment patients and clinic patients?"

"I think the patients before and after treatment are clinic patients," Arias said. "When they are in remission, they are clinic patients. When they are in treatment, they are treatment patients."

"When you get calls from remission patients transitioning from New Mexico Oncology, they become clinic patients?" Miller asked, which Arias confirmed as correct, and said also referrals from providers outside the area become clinic patients until they are in treatment.

Stokes said one of the first PET scan patients was from Las Cruces.

Chief Nursing Officer Peggy White presented her report. "We did open Pod 1 in April, so now we have single rooms for patients. We have had very positive results. Although it has been tight with staff, they have stepped up to meet the needs."

Miller asked if both Pod 1 and Pod 2 have their own nursing stations.

"Yes, and someone is in each," White said.

Miller also asked what a pediatric ready cart is.

"It is in the ER," White said. "It has supplies in the sizes needed if we have a pediatric emergency. It also has medication cards with appropriate doses for children. It's always there for a pediatric emergency."

Trujillo asked what the timeline is for achieving Level 4 Trauma status.

"The state has our application," White said. "We are collecting data and sending a monthly report. It takes about two years to complete. The designation is based on data and how we treat patients coming into the ER. It's very involved."

Miller said: "It's not a money thing, though."

"No, it becomes a quality and safety thing," White said.

Dr. Gregory Koury, Chief of Staff, added: "Then, it becomes a money thing."

CFO Stokes presented his fourth report to the Board of Trustees. "A lot has happened in four months. This April report is for the 10th month in our fiscal year. We made $12,313 in profit, bringing our year-to-date loss to $327,361. This same time last year, we had a $6.1 million loss. That's a turn-around of $5.8 million. It is because of Taffy and JoBeth (Vance, interim CFO) that we have that kind of turn-around. It shows what leadership can do, when they are being able to act and react."

"There were no gimmes in April," Stokes said. "We held six town hall meetings with Gila Regional employees at different times of day to make it easier for employees to participate. Mr. Garcia already talked about the meeting with the community. We got in contact with our attorney on a possible employee benefit and met with insurance. We will probably adopt the recommendation from an employee, which will be a nice benefit for employees."

To a question about it, Arias said: "We have to wait until it's ready to announce."

"I'm so glad this guy was thinking outside the box," Stokes said.

He reported that on April 12, Gila Regional leadership gave a presentation to commissioners. "We completed the transition to HRG for new billing procedures. We are finalizing data extraction from Meditech to HRG on managing revenue processes. We are continuing to flesh out issues, and we are addressing them. HRG is very engaged."

April 17-19 was the JCAHO visit. "On April 22, we moved to single patient rooms. We will maintain the single rooms under normal operating conditions. In the event of a surge of patients, because of some disaster, for instance, we will go back to double rooms."

For patient admissions, Gila Regional had 189, two more than April 2017. Patient days for April 2018 were 437 as compared to 597 last year, but the average patient length of stay was 2.3 as compared to this month in 2017, at 3.2. Stokes said lower lengths of stay are good things.

Emergency Room visits are down year-over-year with this April having 1,343 to 1.426 last year. He said White is working to help create a fast track process at the ER to get patients through more quickly.

Outpatient visits are down to 3,607 for April 2018 compared to 2017 at 3,916. "A lot of this is attributed to not as many oncology ancillary services being done this year."

"But look at our profit of $5.8 million this year," Stokes said. "I look at it and keep it in perspective. When oncology gets humming, it will be frosting on the cake for operating revenues."

To a question about oncology lab services, White said the labs are drawn at the Cancer Center but processed in the hospital labs.

Stokes admitted that he had not spent a lot of time in clinic operations, but "there are opportunities for improvements within 30 to 60 days."

Miller asked if it was because of lack of marketing, with not having a marketing director for a time.

Stokes said it was more the distribution of codes in the physicians' offices. "It should be a nice Bell Curve. For instance, in general surgery, I would expect to see the codes weighted toward high levels of care."

Garcia said: "As they drill down, they are discovering more issues. They are correcting a lot of issues that have been there for years."

Stokes continued with the statistics of his report. Surgeries were up at 420 compared to April 2017 at 319. "There has been an issue with pre-authorization. We have tracked every day the authorization process and those that were not pre-authorized, we don't get paid for. Authorization was received for one procedure and then two or three are done. We monitor pre- and post-surgery, because we have only 24-48 hours to get it fixed."

White explained that something might not have been authorized, but when the physician sees something that is thought necessary, it is done.

"Right now, the physician's office gets the authorization to the hospital," Stokes said. "What we're exploring will secure the authorization for the hospital, without having to call back for the additional authorization."

Trustee Dr. Victor Nwachuku said one of the helpful approaches would have the hospital and the doctor's offices working together "to be on the same page. Maybe we can hire one person to help the two groups work together. The doctor's office passes the authorization to the hospital, but they have to work together."

Garcia said it would be a win-win for the offices, the hospital and the physician. "The services are critical to the patients, from diagnosis to surgery."

"The physician has to do what is right for the patient," Nwachuku said. "When the physician is in the middle of surgery and finds something, maybe cancer, he may stop the surgery, go to the family to get permission from the husband, for instance. Yes, we want to get paid, but we must do what is best for the patient."

Koury noted that if prior authorization is not received, it may end up on the patient to pay the extra costs.

Stokes said it wasn't a "big, big problem, but it is an opportunity."

The changeover in the Cancer Center, with New Mexico Oncology leaving in June 2017 and UNM Cancer Services still coming up to full capacity, although it is ramping up, oncology visits this year in April were 280, as compared to 848 last year. The services continue to increase each month.

Births this year were 28 as compared to the same month last year at 23.

In key performance indicators, Stokes said cash collections were down at $4.9 million, compared to last year's 5.3 million. "I attribute that to uncompensated care."

Days of cash on hand are 72.63 days compared to last year's 70. Days in gross accounts receivable are 69 compared to 46 last year, with days in accounts payable 56, compared to 45 last year. "The correlation between AR and AP shows that we are still burning internal cash."

Daily expenses have dropped to $180,321 from an average of $198,799 last year. Daily gross revenue is $550,709 compared to $583,831 last year. Daily net revenue is $199,700 compared to $200,609 last year, showing that lowering expenses is bringing daily net revenue to a better level. The number of full-time employees is 491, compared to 529 last year. Overtime expenses are at 3.6 percent this year, the same percentage as last year. The current ratio of assets divided by liabilities shows 3 percent this year, as opposed to 2.7 percent last year.

Stokes also gave a look ahead for May, based on month-to-date, which shows an expected inpatient admission rate of 182, with patient days 585, daily census at 20.9 and average length of stay at 3.2 days. ER visits are anticipated to be 1,383, out-patient visits at 5,029, surgeries at 393 and oncology visits at 356.

"We are trying to vet data out of Meditech, so that we can rely on it," Stokes said. "Over the next 60 days, we will be vetting the numbers. We have got to figure out how to rely on the system numbers."

Arias noted that the look ahead for May was only estimates. "For instance, oncology is closed today and Monday. We will continue to refine the process."

Miller asked about uncompensated care and the amount recently received by Gila Regional for 2016 uncompensated care. "Do we plan on getting the funding each year?"

"No, we do not plan on it," Stokes said. "This year's uncompensated care will have reconciliation next year."

Trujillo said the hospital used to budget the expected returns of uncompensated care funding. "That's what got us in trouble."

"When we receive it," Stokes said, "it shows up as a contracted reduction."

Miller asked if self-pay or Medicaid shows up in revenues.

"If it's a self-pay of $1,000, for instance, it shows up in revenue," Stokes said, "but $810 will sit in contractual reserves. In order to claim Medicare, we have to hold it for 120 days. Self-pay has not been managed correctly."

Miller asked, when looking at the balance sheet, why the fund balance is considered a liability.

Stokes said liabilities plus equity equal assets. "It represents how much excess the hospital has recorded over the years. We are positive in equity."

"Now for the good news," Stokes said. "It's been a hard several months, but Alfredo (Pacheco, controller) sent me a letter received from CMS (Centers for Medicare and Medicaid) about our low volume payment. The federal government had cut the low volume payments, so we haven't been receiving any. Congress reinstated the payments, so now the hospitals have to apply. We got an email saying we have been approved for $200,000 this year. Alfredo managed all of that."

Koury presented his Chief of Staff report and said the physicians recently recognized the IT department members. "Different ER practitioners worked well together on a recent case. And our CEO is starting to wander. She was seen recently visiting a surgery."

"I was in surgery and joking around," Nwachuku said, "and there she was."

Garcia asked for clarification on a Surgery Department employee leaving.

"Nurse Fran Driver has stepped down from being Surgery Director," Koury said. "And the Medical Executive Committee sent a concern to the County Commission. One of the members of the task force on what to do with the hospital is already talking to Lifepoint about an urgent care clinic in Lordsburg. The item was disclosed by the individual to Commissioners Brett Kasten and Alicia Edwards, but not to the physicians. We feel there is no transparency about this process. This was prior to their presentations to all groups."

[Editor's Note: Dan Otero, Hidalgo Medical Services CEO, mentioned the potential for a new urgent care clinic in Lordsburg in a recent gathering, but not the details.]

"We appreciate the MEC stepping forward," Garcia said. "Thank you, Dr. Koury, for being diligent."

As part of the Chief of Staff report, trustees approved the 2018 Peer Review OPPE (ongoing professional practice evaluation) Charter Policy.

Trujillo presented the Quality Improvement Committee report, including the quality and patient safety report.

"We are seeing a reduction in readmissions, due to multi-disciplinary efforts," he said. Referring to the dashboard for the committee, "We are seeing efforts between the CNO and Chief Quality Officer to address 'red' issues. Because of quality efforts, our committee is meeting monthly again. I would ask the board to consider adding a CQO report to the agenda." He suggested later that such a report could replace the Quality Improvement Committee report in and after the executive sessions.

Nwachuku agreed to having a CQO report. He said quality is one of the most important things in the hospital. "She must communicate with the physicians and the patients to see what they think. The physicians may not be aware of what's happening."

"That is part of the strategic plan," Carroccio said. "The Patient Experience Committee will get the information back to the physicians and nurses."

Trujillo said the CNO and CQO are working together.

"I'm just amazed at what our CNO does," Miller said. "I want to ask about the culture of safety survey."

Carroccio said about 260 had been received, which was about 50 percent of those sent out. "We want to push it to 75 percent. We will have good data."

"Hooray, our quality is up there," Garcia said, "but our team is still looking forward to the best quality care for patients. As Mrs. Arias says, patients and their families are the most important thing in the hospital. We want to be the best. We challenge all teams to push forward."

"We're working on our 5-star quality plan," Carroccio said.

Stokes said: "Clinically this hospital is outstanding. Finances – not so much. I have taken up the challenge to get finances up to the same level."

The Finance Committee asked for and received approval of several contracts: a first amendment to the professional services agreement for on-call anesthesiology service coverage by Aaron Rudd, CRNA. A first amendment to pain management and anesthesiology provider employment agreement allows Dr. Craig Leicht, who although he has left the area, to hold a clinic one day a month and do procedures two days a month, so the patients will not be without care. A first amendment to the lease agreement by and between GRMC and HMS is for a three-month agreement to provide an office to HMS interns in a building in Bayard, owned by Gila Regional.

Garcia clarified that all contracts are being watched, because of uncertainties.

In the Plant and Facility Committee, Miller said the safety folks are planning an expanded active shooter safety drill that would involve the first floor of the hospital. JCAHO issues with the Behavioral Health Unit are being worked on and they hospital expects to complete them within the next two to three weeks. She also said that the New Mexico Health Information Collaborative has completed the process so that some people coming in from outside can get information out of certain medical records.

Garcia asked if there had been any consideration of having mock drills at the schools.

"We are looking at it for fall," Carroccio said. "We have talked about all the schools, including the university."

Stokes said a hard kick-off meeting had been held on the Meditech upgrade set for Aug. 22. "We want to avoid what happened last year and the corrections we've had to do. We have engaged with Navin-Haffty to make sure we stay on track. The Meditech 6.1.5 functionally will be so much better. We want to install a quality module for reporting."

Miller added to her report by saying that Robert Candelaria had been promoted to the top position in IT, although positions in the department were still open. "We are also working on a draft of a letter to the providers in town to determine their interest in being able to access the Gila Regional system."

Koury confirmed the interest. "We will see very little changes in the Meditech upgrade for us."

Nwachuku noted that Arias had attended the Independent Physicians Association meeting. "We were happy to have her there. We are thinking about joining other bigger networks of IPAs across the state to benefit us and the hospital."

Trujillo said the Human Resources Committee did not meet, but at the end of April, the hospital had 619 employees compared to 711 last year. "That includes the total number of caregivers, full-time, part-time, and PRN (pro re nata, Latin for as needed). The total number leaving the hospital year-to-date is 138, compared to 163 last year. That's a gross percentage turnover of 23 percent." Turnover among employees continues to be a concern, with housekeeping seeing the largest numbers of turnovers, in addition to too many nurses leaving. Applications continue to come in. Overtime hours are about the same, with a slight decrease, although dollars increased to a little over $1 million compared to about $900,000 last year. Contract labor year to year has cost about $4.1 million.

Chris DeBolt, who usually speaks in public input, but did not at this meeting, asked to speak.

"I wish other people would be here to listen to what it takes to do this well," DeBolt said. "Many people support you out in the community and want the commissioners to make the right decision to keep the hospital as it is."

Koury said: "I want to add to the safety moment. We had downtime on the CT machine, but no one informed the physicians. We are looking at a process of letting the MEC (Medical Executive Committee) know about scheduled downtimes, so they know when they will happen. A physician needed it for a patient, and it wasn't available."

"I have told the technicians that downtime has to be after hours, not during prime daytime hours," Stokes said. "Yes, someone may need it at night, but it's less likely."

The trustees took a 15-minute break before going into executive session. No extraordinary business was expected afterward.