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[Editor's Note: This is part two and the final of a two-part series of articles on the GRMC Board of Trustees meeting on Nov. 30, 2018.]

At the monthly regular meeting of the Gila Regional Medical Center Board of Trustees meeting on Nov. 30, 2018, the board members heard reports and updates from staff and leadership.

Eileen Smith, representing the GRMC Auxiliary, said the report was in the packet. Board Vice Chairman Dr. Victor Nwachuku asked what events the auxiliary would be holding in December.

Smith said the members would hold a jewelry sale on Dec. 14, and a bake sale on Dec. 19.

"I would like to thank the GRMC Foundation who made turkeys available for the Thanksgiving baskets," Smith reported. "We also have a hospital employee who purchased 18 gift certificates of $20 each to put in the baskets. Each department gives us a list of those who may need baskets of food at Thanksgiving."

Chief Executive Officer Taffy Arias highlighted aspects of her report.

"The Family Clinic hired a nurse practitioner who will start Jan. 1," Arias said. "We have a urologist who is working on his credentialing and preparing to start working when it is completed. We will hold a ribbon cutting at the podiatrist, Dr. Iwaasa's practice on Dec. 14. He is already working and has received approval to start foot surgery.

"We extended an offer to a full-time oncologist," she continued. " We hope to hear back today. The community came together yesterday evening (Nov. 29) for the 13th annual Light Up a Life. It's always a powerful ceremony. We have latticed walls for photos of people and pets who have left us. Dr. (Gregory) Koury gave a powerful speech."

She said that Dr. Iwaasa's office is doing a shoe drive for the holidays.

"We will be presenting on the Stepping Up Program at the Detention Center," Arias said. "We are also working with immigration authorities. It is becoming an issue to treat those coming into the country. It used to be 10-12 coming at one time. Now it's 300 at a time. It's becoming an issue for emergency rooms."

She said the Trunk or Treat event on Halloween was attended by more than 2,000 people. "I think we had 30,000 pieces of candy." She thanked Trustee Joel Schram for First American Bank's donation for candy.

Trustee Ed Wilmot asked about an issue that was brought up by Arias at the November County Commission meeting. "It was about the hospital no longer being able to use ambulances to return people to their homes."

"We have met with all the offsite agencies and Charlene (Webb, county manager)," Arias said. "Sometimes people are being discharged to their homes and sometimes to nursing homes or assisted living facilities. We are all working together to find a solution.

"It was an issue where CMS (Centers for Medicare and Medicaid) put us on notice because of inappropriate use of transport," Arias continued. "The issue was their denial of bills we were sending. Because of the volume, they were denied. CMS told us to stop it immediately. We did. The speed at which we reach a solution is crucial. We have to explain to the community the issue."

Nwachuku said when he sends a patient to another hospital, it is because "I don't have the ability to take care of them here. I have to give a reason and it has to be that they need a higher level of care than we can provide here."

"That is two separate issues," Arias said. "When you transfer them to another hospital, that is not being denied. It's when we were trying to help patients get back to their homes or nursing home or assisted living after discharge from the hospital."

Nwachuku pointed out: "If we send someone to UNM, that person will have to find his or her way back home."

Trustee Jeannie Miller asked about the nurse practitioner at the Family Clinic. "Where will the position be? And will the clinic be for anyone?"

Arias said the nurse practitioner will be opening the Bayard Clinic, which will be open to anyone needing medical care.

Miller also asked about the oncologist and what days the physician would serve. She asked about the oncologist who had been recruited and was still interested but would not finish her fellowship until June.

"The full-time oncologist will be Monday through Friday," Arias confirmed. "And we had not made an offer to the one serving her fellowship. We made a proposal, not a contract. If the person we just made an offer to accepts, then we will withdraw the proposal to the woman oncologist."

Trustee Tony Trujillo said he was concerned whether, with volumes at the Cancer Center increasing, if patients were having adequate time with the doctors. "Are you discussing this with UNM?"

"They are working closely with us," Arias said.

Trujillo suggested maybe a way to contract with others "while we get over the hump of volumes being up."

Arias said it had to do with protocols. "It's good the volumes are up."

Miller asked if the radiation oncologist would continue in the position, to which Arias confirmed the person and position would continue. "We are also looking at additional contractors," Arias said.

Wilmot asked if the hospital had spoken to the new essential air service provider, Advanced Air, about the hospital's trouble in getting doctors from Albuquerque to Silver City. He was assured that Advanced Air knows about the situation and has plans to address the issue.

Chief Nursing Officer Peggy White, in her report, said she and the interim Emergency Department director are doing an in-depth analysis of the ER. "We will be working closely together to move to a strategic process in the ER. He's an independent contractor acting as working director, while he gets his New Mexico license. We meet almost daily."

Miller had questions about the automated call back system. White said it's to make sure there are follow up calls. "We can help set up appointments with the primary physician, for instance. Right now, it's only for in-patients, but we want to expand it to outpatients. The system automatically lets the ones calling that the patient has been discharged, so they can follow up."

Another question from Miller addressed the discharge processes for the Border Patrol when it is in illegal alien being discharged.

"The Border Patrol has medical providers at the facilities we send them back to," White said. "The process is that the information has to go from health care provider to another health care provider, with no one in between having access to the information."

Chief Quality Officer Tanya Caroccio said it's the way to make sure the patient is confident in how their information is handled confidentially.

In her report, Caroccio said the hospital is seeing the KETO diet in the community. "Case management is setting up a workshop with doctors to educate anyone involved, including the doctors and the dieters. Anytime the case management team sees a new thing in the community, they try to educate those involved. We will do the same thing for diabetes training."

Caroccio said with the hospital's focus on quality, the new quality module of MediTech is helping the hospital deal with sepsis, UTIs (urinary tract infections), and other potential infections based on labs. It's an early warning system on patients. We get information and pull it together and the system spits out what's happening with the patients. We get the trends in real time, so we can address them rapidly."

She said the hospital's event reporting is "archaic. It's a paper system. We need it to be more robust. We will kick it off over the next couple of months, but we need some more hardware, more servers. We anticipate it early next quarter. The surveillance a lot of resources."

Nwachuku asked if the hospital has seen a lot of patients brought in by the Border Patrol.

"We, hospital leadership, and the Border Patrol had a roundtable meeting and came up with a process to identify a person for viable communication with our risk manager," Caroccio said. "Agents that have come in, I have received so many compliments on the wonderful care we give."

Schram said a lot of information on the caravans has been in the news. "Are we working on the potential of our ER being overwhelmed?"

Caroccio said some areas of the border are seeing 300 a day. "We are working on an early warning system."

White said: "We are not seeing dangerous people. We are seeing the ones who need care."

Caroccio said a lot of the cases have been pediatric.

Arias said that many of those needing care are not emergencies. "We are setting up a time for me to go to the border and see if we can help." She said ICE has been "quick to tell us they have no funding to pay us for care. Many are already coming into El Paso, Columbus and Antelope Wells."

"We treat them as we treat any patient that comes through our hospital," Caroccio said. "They have the same privacy rights. We have set up strict restraints."

Marketing Director Doug Oakes reported on the new signage for the hospital. "We have temporary signage up until we get the request for proposal out and answered to put up permanent signage. We have put out new promotions of our mammography and new service promotions, such as our new podiatrist. On social media and on The Grant County Beat, our ad impact is trackable. We have had a contract with Dex Media, but it has not been very effective. We would like to create a new digital campaign with our website providers. We publish ads and news releases in print, on the Beat and on the radio, all of which are very effective. I want us to be able to control where we put out information. There is a tremendous amount of ad fraud, and it is rampant on social media."

The Chief Financial Officer's report was presented by Controller Alfredo Pacheco, in the absence of CFO Richard Stokes.

Pacheco said October was "a solid month. I will focus on this year's numbers compared to last year's. At the end of October, we had an almost $600,000 excess revenue over expenditures as compared to last year negative $446,095. Year-to-date for 2018, we are at negative $281,944, but that compares to last year's negative $4.5 million, a $4.2 million variance. Last year for the first quarter, the hospital was digging a hole. The last three quarters, we were digging out."

He noted that the first three to four months of the fiscal year are not the high dollar months for Gila Regional. The EBIDA (earnings before interest, debt and amortization) at the end of October was a positive $997,251, as compared to last year's negative $107,439, a $1.1 million variance. Year-to date EBIDA is $1.3 million as compared to last year's negative $3.1 million.

The unbilled amount for October 2018 was $3.1 million. "We are working it consistently downward. We want it closer to $1.5 million."

Pacheco said the Quadax Clearinghouse went live as expected. The Pharmacy Drug Charging functionality went live as expected. "We are continuing to work on the contract with Western Sky for managed Medicaid. We also completed work on the fiscal year 2018 Medicare Cost Report, which has been sent. Richard stressed that it was important to get this report correct."

Volumes are similar, with 151 patient admissions for October 2018, as compared to 154 in 2017, with average daily census at 16.1 and average length of stay at 3.3 days in October 2018.

He noted the outlier of more outpatient visits, because it was reported incorrectly in the past. Cash collection was up at $5.1 million for October compared to $4.2 million in September. Days cash on hand is 68.8 compared to 60.4 in September of this year.

"Accounts receivable was positive in October," Pacheco said. "September has high AR and lower gross revenue. The trend reversed in October, with higher gross revenue and lower AR.

"In a look ahead for November, overall November will not have October numbers, so I don't expect great revenue," he cautioned. "We will use a type of graph to show trends to point out the seasonality of health care. October was a good month for us. We are balancing out and cleaning up processes."

Wilmot said: "In the strategic plan, we have some projections for savings and opportunities. At some point, will they be expended, so we have a new baseline? And when might we be at that state?"

Pacheco said: "Since Richard came on board, the commission has been a focus, but our primary focus is the revenue cycle. We continue to find problems and correct them. It's ongoing. We are working to get to the point of more consistency, where there is more analysis and less reporting, so we can do deep dives."

To a question from Wilmot about going critical access, Pacheco said the hospital would need capital on hand for going critical access. "We need a big black number. We need to work on capital, so we can also fund human capital."

For the HRG consultant firm report, Pacheco said they plan to go through it with the individual trustee members. "We will be posting our service charges. We are working with IT to get it out there."

Schram said EBIDA is really cash coming in through operations exclusive of writeoffs and interest. "It's basically the cash that's coming in."

Board Chairman Mike Morones noted that cash on hand went up and accounts payable went down.

"We are managing our timelines," Pacheco said. "We try to take care of our bills, especially our local bills. As they say: 'Cash is king.'"

Nwachuku said that the most important job of the Finance Committee is "getting money coming in."

The Chief of Staff Dr. Gregory Koury was expected to attend, but let the members know that he could not.

The trustees gave board committee reports.

Morones said the Executive Committee developed the agenda for the meeting and has recommended that the December meeting, which would usually fall between Christmas and New Year's Day should be moved up to Wednesday, Dec. 19 at 8 a.m. He explained it needed to take place in December because of contracts that need to be completed before the end of December.

A motion was made and approved to cancel the regular meeting, which would have taken place Dec. 28, and to hold the special meeting on Dec. 19.

Miller presented the Quality Improvement Committee meeting report. "We have a strategic plan to move the hospital toward a 5-star rating. As it is based on the 18-months prior to the designation, our next rating will include 2017 and we may see a rating drop. We are working on getting indicators up. Five-star rating puts the hospital in the top 10 percent of hospitals across the country. Only 252 were awarded in 2016."

Caroccio said the hospital is determining whether some infections such as C. diff, which is fecal related comes in with the patient or is contracted at the hospital. "We are doing the same with sepsis, which can attack the organs. Quality is working heavily interdepartmental. The Leapfrog report is based on publicity reporting. We did a staff survey on the perception of safety and safety concerns. We have presented a list of greatest concerns with solutions and who is responsible, so the staff know it's being taken care of. We are doing a mock JCAHO (joint commission) survey to help staff with answering the kind of questions that get posed during a JCAHO visit and to make sure safety is a priority."

Nwachuku asked if any areas need improvement. Caroccio said sepsis and C. diff are focus areas. "We are keeping on top of new infections. Even though we think no C. diff is gotten in the hospital, if we take too much time to find it, then when it's found, CMS (Centers for Medicare and Medicaid) says: 'You own it.' We are also looking at value-based purchasing. CMS gives us points if we are improving and takes points away if we are not. This is all tied to reimbursement rates. Quality and safety are important to us. We take our numbers and plug them in. The rating can last for 18-24 months, but you have to continue to work to maintain the rating."

Wilmot said he still has concerns about the policies and procedures document. Delicia Dimberg, Medical Staff Services director, said they will be brought back to the board for further consideration. Wilmot said he appreciated the time Dimberg spent educating him on the issues.

"You will have a clear explanation for every change," Dimberg said.

Schram presented the Financial Committee report. "We had a good discussion about accounts receivable and the unbilled items. Quality drives the reimbursement rates. We appreciate the work the QIC is doing. A lot of good progress is being made."

Morones said the hospital can never remain "comfortable. We always should be a little stressed."

Arias said there was no shortage of that.

Miller gave the Plant and Facility Committee report. She said Emory Coleman, the facilities director and Gilbert Jaurequi on medical equipment continue to work to keep everything running well. "Emory is drawing up MOUs for off-site vendors, so if equipment goes down, it will shorten the response time."

She said they also talked about fire safety and protection and security. "An annual hazard vulnerability report is required by CMS. This year our highest risk was a mass casualty incident, such as a shooting or accident. We get a lot of information from the staff members who come to our meetings."

Nwachuku asked if the hospital works with the mines and schools and whether there is a plan.

"We work with all of them," Caroccio said. "We will work with the schools for an active shooter drill early next year."

Wilmot questioned the 100 vacancies listed on the hospital website.

Arias said many hospitals don't put all their openings on their websites. Caroccio said that often means they are not being forthright about how many vacancies they have.

Nwachuku asked about traveling nurses. White said the number was much higher than what she is comfortable with, but "we're engaged in an initiative to lower the number."

Trujillo noted that contract costs remain high.

Morones requested more detail on the contractual costs.

On the issue of the bylaws, Morones said it might be valuable for trustees to meet and look at how processes work with the bylaws.

Wilmot said he would like to see how to restructure things to have more open discussions with the commissioners.

Nwachuku said there is a need to make sure no conflicts exist between the physician bylaws and the hospital bylaws. "We should have a discussion in a general staff meeting."

The trustees took a break before going into executive session.

Live from Silver City

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