By Mary Alice Murphy

The regular September meeting of the Gila Regional Medical Center Board of Trustees was moved to Oct. 5, 2018.

It opened with a safety moment, when Chief Nursing Officer Peggy White said she and other staff members are aggressively looking at processes in the Emergency Department to implement Fast Track to speed up less urgent cases that come into the ER for care.

"Kelly (Rodriguez) and I are doing in depth evaluations," White said.

Trustee Dr. Victor Nwachuku, board vice president, chaired the meeting.

The next item of business was introductions, announcements and recognitions. Yvonne Maxwell was recognized for her 20 years of service in the operating room. Also recognized was Carolyn Torres for her 15 years in labor and delivery. Nwachuku said he has had the opportunity to work with both. "I appreciate their service."

Chief Executive Officer Taffy Arias said she had another recognition. At the recent New Mexico Hospital Association annual conference, Gila Regional received an honorable mention award in case management.

"This is so important," Arias said. "What is also important is what happens when a patient leaves the hospital. Case management makes sure patients get to their doctor's appointments and that the patients know how to take their medications."

Nwachuku gave his own endorsement of case management staff. "You have changed what you do in the hospital, and we really thank you for your service."

Another announcement came from Silver City Daily Press reporter Ben Fisher, who said it would be the last meeting he would cover for the hospital. "I got a politics and government desk job at a newspaper in Iowa."

"For Ben and Mary Alice, I thank you for your coverage during our difficult time of transition," Arias said. "We want to thank you for your support through the good, bad and the ugly."

Trustee Ed Wilmot said, without Fisher's coverage, it would have been difficult to find out what was happening. "A lot of people depended on you, and Mary Alice, too, absolutely, but he's leaving."

During board input, Trustee Jeannie Miller said she likes the pink shirts worn by the Emergency Medical Service staff. "They are really cool. I have also had many people tell me they really appreciate the digital mammograms, because they are so much better."

Trustee Tony Truillo said it's always good to come back from vacations.

Wilmot agreed and said there are benefits to being away, "but it's difficult to catch up. You wouldn't think missing one meeting would make me feel lost, but it did. We need to try to communicate better."

The first report/update was presented by Jennifer Yost, Auxiliary president. "We have a couple of new volunteers and two more have interviewed. We continue to serve Cancer Center meals, where the numbers are up."

White recognized the Auxiliary for donating money toward nursing scholarships.

"We raise money various ways," Yost said. "We had a bake sale in September, will have a jewelry sale in November and another bake sale in December." She noted that associate members do not serve but are recognized for having previously been active or for providing support.

Chief Financial Officer Richard Stokes thanked the Auxiliary for having two representatives at the annual NMHA meeting. "There were a lot of auxiliary members from all over the state."

Although no one gave a Foundation report, White said the foundation donated $8,000 to nursing scholarships.

Arias presented the CEO report. "One highlight, the family practice, I will pull into executive session. But we interviewed a urologist, made an offer and it was accepted. The new urologist met with Dr. Lash. The new doctor does a higher level of practice and surgery that we will be able to keep in Silver City, without having to send people out. We have offers out to surgeons, because Dr. (Maximus) L'Amour will move to Santa Fe with his wife in mid-December."

"We also have an offer to a physician who is finishing her fellowship in oncology," Arias said. "She is still interested. She said she appreciated the way she was treated here when she interviewed, and she was very positive about the way we would take care of her and her child."

Arias said a new podiatrist would start in three weeks. "The Cancer Center is picking up in volume. We have had problems with Boutique getting our physicians down here on Fridays. There have been some cancellations."

Trujillo asked if the hospital is looking for a Foundation director. Arias said it would be a part-time position, with the person also doing grant writing for the hospital.

Trujillo requested a job description. "I wasn't convinced a full-time person was needed for the foundation."

"We combined the two jobs, so it would be two part-time positions," Arias confirmed.

Miller asked about the interim perioperative director.

Arias said with a podiatrist and a urologist coming in soon, "as part of our strategies, we have hired staff to manage the expansion in surgery. We hope she accepts full-time from her interim position."

Miller also asked if the radiologist was full-time, to which she was assured the position was full-time. "I hear that Shelly Carter is leaving as director of the Cancer Center."

Arias confirmed that. "Shelly misses the beside role in nursing and doesn't feel like administration is where she wants to be. We have started an interview process to replace her."

In the Chief Nursing Officer report, White highlighted that she continues to assess the situation in the Emergency Department, where volume is down slightly.

Wilmot asked for clarification on which project was on hold.

"(The particular surgical Meditech module) is on hold because of the interim surgical director and with new physicians coming on board, we have given the director a reprieve so she can get them on board," White said. "We may move it to another department, to give her some time."

"We have had operational review of surgery and are working on optimization," Stokes said.

"We are still giving discharge instructions," White said. "They are just not coming out of the Meditech system."

Miller asked about communication with doctors. "It is the application we will talk about in the Quality Improvement Committee report."

White said if a patient is in the ER and will be admitted, the doctor gives the bridge orders until the hospitalist can see the patient.

"Do we do succession planning?" Miller asked.

"Currently we are not doing it," White said. "We will revisit it, but right now we have no Emergency Department director, so Kelly and I step in where needed."

Miller asked about the status of the Level 4 Trauma Center, with Dr. L'Amour leaving. "Is it under the ED, or is it a staff director or…"

"We hired a nurse coordinator, who has experience in trauma," White said. "She stepped right in and kept the process going. We will work with the ED and anyone with trauma surgery experience. The project process is moving forward."

Miller commented on the pediatric standards. "Do we have many pediatric patients?"

"Pediatric surgery and ER is a low-volume, high-risk population," White said. "But pediatric is considered from one month of age to 18 years of age, so in the group, we see a significant number of patients. All our ER doctors are certified in pediatrics and our pediatric physicians round in."

Chief Quality Officer Tanya Carroccio, in her report, said: "Flu season has arrived. We are pushing staff members to get a flu shot. We are doing a robust campaign. We are also looking at policy changes."

Trujillo said it's a historical issue in the hospital. "Do you offer any incentives?"

"It's usually a political or personal reason why they don't get the shots," Carroccio said. "We had conversations with other hospitals, and their level of participation is not as low as ours. We're exploring what will be best for here."

Trustee Dr. Tsering Sherpa said the hospital has to determine the reasons. "Maybe they think they have an allergy. We can do a skin test for that. We have to tackle the different reasons."

Carroccio said they have to educate toward the declinations to get the preventive shot.

Nwachuku said that the flu shot should be available at all staff meetings.

"Maybe we as trustees, need to do a PR campaign as champions of getting the shots," Trujillo suggested.

"We will continue to focus on the culture of safety and getting staff input," Carroccio said. "I want to give a shout out to the physician champions, such as Dr. Sherpa."

Carroccio said the Centers for Medicare and Medicaid awarded the Health Research and Educational Trust (HRET) a two-year Hospital Improvement Innovation Network (HIIN) contract to continue efforts to reduce all-case inpatient harm by 20 percent and readmissions by 12 percent by 2019.

"We already mentioned the NMHA award we received," Carroccio said. "Earlier this week, we were asked if we wanted to receive any of the left-over HIIN funds for scholarships. They had $2,500 available. As a result, Denise (Baird) will attend the Health Improvement Innovation Network conference and will bring back information. On another note, the NMHA asked me to apply to be on the Quality Committee, so I put my name into the hat."

Wilmot asked how the risk manager has integrated into the system.

"Amazingly well," Carroccio replied.

"I was rounding," Stoke said, "and talking to the med surg nurses. They said they were really impressed at her scope of knowledge, and that she was helpful on an issue that very morning."

Wilmot asked what the primary risks in Gila Regional are. Carroccio said she is doing an assessment.

"It's important to identify the issues and implement the solutions," Nwachuku said.

Stokes presented his CFO report. The net profit in August, the last approved monthly report, was $176,316. Year-to-date the excess revenue over expenditures was negative $337,723, as compared to last year's negative $2.2 million. The EBIDA (earnings before interest, depreciation and amortization) added $557,816 to the bank account, he said. "Year-over-year, we have an improvement of $2.5 million."

For the revenue cycle update, Stokes said the hospital has a known issue with unbilled reporting through Meditech. "In cash collections, we collected $5.4 million, the highest collection in 14 months, with 33 percent of charges converted to cash. Cash to net, we had 140 percent of what we expected to collect over collections in July."

On the Meditech update, he said the hospital had completed 835 corrections/rebuilds, with 837 coming back into the hospital. "The file wasn't built correctly. We have corrected it, and we're billing secondary insurance and patients' portions."

"We continue to optimize the pharmacy module," Stokes said. "It had no logic. We are testing it and the go-live date is Nov. 5. We will base charges on a table, so there is some logic on how to charge patients. To make modifications, we will modify the table. For example, one of the chemo drugs was entered at $19,000. We will move it to $9,000, and there will be no bottom line impact to the hospital. There is no need to charge that much to the patient. The vast majority of the medications will go down, with a few going up. It is putting logic into the process."

He said purchasing has achieved 90.1 percent compliance rate with the group purchasing organization. "We were below 80 percent, so we're happy about that."

Days cash on hand stand at 72. Days in gross accounts receivable is 63.5; and in accounts payable 52. The case mix index was 1.46. "Volumes jumped a bit in August."

In a look ahead, the news is a bit less favorable. "Historically, September, October and November are low. January, February and March are usually our largest months. We continue to work net revenue, but we expect our monthly revenue to be down about $2 million."

Miller asked what current ratio means.

Stokes said it is assets divided by liability. And to explain the case mix index, he said it indicates the severity of illness. The higher the ratio, the sicker the patients.

Arias said the case mix index also addresses the length of stay. "They move down together. The problem comes in if the case mix is low and the stay is longer. We lose money on that every time." She said it depends on the DRGs (diagnosis-related group) from the physicians. If it doesn't mention the co-morbidities, it is not codable or payable.

Stokes also talked about the HRG consultants' report, identifying the hospital payer mix and accounts receivable composition. "Last month, we received 17 percent from Medicaid. This month it was 21 percent. For Medicare, last month was 26 percent and this month 36 percent. Self-pay was up and so was commercial."

Wilmot asked about the contracted pharmacy operations. "Are you tracking them?"

Stokes said the hospital is not tracking the separate transactions, but only per discharge.

"If it's good news, we should tell the public," Wilmot said.

Arias said with the pharmacy, some things are not just financial, but also quality. "There have been improvements there. We are seeing a lot of clean up. We also identified legal issues and how drugs are released from the pharmacy. We supplied drugs for many years to Silver City, but now it is specifically to the Fire Department. All of this has been cleaned up."

Stokes said another major initiative was the pharmacy Meditech module. "Issues have been corrected. Cardinal (the pharmacy contractor) and HRG continue to review things. We've had corrections through both."

Nwachuku said the Financial Committee has done a lot of digging. "Collections have improved as we drill down. We still see some areas of improvement."

"Oh, yeah," Stokes said. "We're just kind of getting started. If a separately reimbursable drug was not reported correctly, it was a denial. Now, it's correctly reported.

"We're implementing a new clearinghouse module," Stokes said. "It will give us input on where the denials come in. It is a build on to Meditech. We wanted to get down to the line item identifier. It should go live in December."

Wilmot wondered when the hospital will hit a new baseline.

"Probably in six to 12 months," Stokes said. "We are having a study done in surgery to optimize it. We continue to have opportunities. If we hit 35 percent collections, we can't say that's good enough. We can't stop there. Every morning we talk about issues and how to make the hospital better. I say: Don't get satisfied. We continue to have opportunities for improvement."

Nwachuku said it is crucial to continue to work on the financial health of Gila Regional.

"We are initiating a partnership that helps the hospital negotiate contracts, not just the rates, but also the terms," Stokes said. "Our goal is to renegotiate all our contracts, so we can load the terms into the system to let us know if we are getting paid correctly."

Chief of Staff Dr. Gregory Koury was not present, so Nwachuku gave a brief report. "We have ongoing professional practice evaluation of physicians' behaviors. We have to be in compliance with our bylaws and policies. We continue to work on how to get physicians to be in compliance with Meditech. Any decision goes to the OPPE committee and then to the Medical Executive Committee for ultimate decisions."

Miller asked about the physician application.

Arias said it is based on the answers physicians give in their applications. If it brings up red flags, such as gaps in their license, gaps in their work or other problems.

"We have to make sure the application is not cumbersome," Nwachuku said. "We have to make it friendly. If it's too difficult and takes two to three hours to complete, that's too much."

Nwachuku said the Executive Committee approved the agenda.

Miller presented the Quality Improvement Committee report. "We met and talked about the culture of safety action plan that is being developed. We also talked about the quality assessment and assurance plan, an annual plan that was approved by the committee. We talked about our 5-star rating plan, with three things to focus on. We are working on lots of things, including the SBAR (situation-background-assessment-recommendation) communications format. We brought forth an item—an evidence-based clinical tool having to do with medications and other orders. We talked about trying to pilot it through the hospitalists and the ER."

Sherpa said she spoke to Koury about it, and he remembers it as good. "We'll talk about it at the MEC and then go ahead with it."

"How can the board show that we are behind you?" Miller asked. "We need to think about how to make a statement about the evidence-based and value-based processes. We can think about how the board needs to take a stand on issues."

Denisha Dimberg, director of medical staff services, said the MD application form is now totally paperless. "This one is more robust and specific. We planned first, and the application followed."

Nwachuku gave the Financial Committee report. "Our finances are getting better, which we are very happy about."

Several contracts were approved for extensions through Jan. 31, 2019. Arias explained to the Beat after the public meeting and before the executive session that the short-term extensions are being made while the entire contract process is under review to ensure that all components are in compliance.

The following professional services agreements for on-call specialty service coverage were approved one-by-one for extensions from Oct. 25, 2018 through Jan. 31, 2019:

Orthopedic surgery-Carreon, Roberto, MD
Pediatrics- Davenport-Reed, Laura, MD
OB/GYN- Diaz, Michelle, MD
Pediatrics- Koury, Gregory, MD
Urology-Lash, Amos, MD
OB/GYN- Nwachuku, Victor, MD
General Surgery- Odocha, Okay, MD
Anesthesia – Rudd, Aaron, CRNA
Critical care/pulmonary- Stinar, Donald, MD
General Surgery – Wendler, Frederick, MD
Anesthesia- Williams, Nathan L., MD and
Anesthesia- Zerger, Dan CRNA.

The final contract approved was a physician employment contract for Iwaasa, Gregory, DPM (Doctor of Podiatric Medicine)

For the Plant and Facilities Committee, Miller said the hospital is recruiting for an information systems analyst 1. "We are working on things in the queue. We had no equipment level 1 malfunctions last month. We are discussing what type of plant contingency plans are needed. We should have it in about six months. We will have an active shooter drill that takes place at a different facility and the people are brought to the hospital. We will use the SBAR format for our meeting minutes. In September, we had 177 security standby hours. They get called to make sure nothing happens."

Trustees Mike Morones, who attended by telephone, gave the Human Resources Committee report. "We have critical vacancies that need to be filled."

Nwachuku asked about the traveling nurses' situation, because the prior month had a number of them at the hospital.

"We are concerned," White said. "We have a plan in place. We hope within two months not to have any in maternal/child. Our next goal is to have none in the OR or ICU."

The members took a 15-minute break before an executive session.