By Mary Alice Murphy
The first item of business at the Gila Regional Medical Center Board of Trustees meeting on Feb. 22, 2019 was the usual Safety Moment. Kelly Rodriguez, interim chief nursing officer, said home visits would be arranged at the office to keep visitors safe.
Three staff members were recognized for their years of service. Mary Ann Aguirre has served 40 years in the Operating Room; Gilbert Jaurique, 25 years in Maintenance; and Veronica Maynes has spent 15 years of service in First Born and Beginning Years.
No one signed up for public input.
Board members presented input.
Trustee Dr. Victor Nwachuku said the finances are continuing to get better. "I commend everyone continuing to change things to improve the hospital. Some things we need to do include to make structural changes, especially the recovery room and the labor and delivery facilities."
Trustee Ed Wilmot said he was concerned when he found out about the Chief Nursing Officer resigning. "It caused me to reexamine my concerns. She left in a hurry, it seemed. The chasm in board issues that I have doesn't seem to get resolved. I have documented my concerns in a confidential letter to the board. I need clarifications, and I intend to give the letter to the commissioners. I continue to struggle with issues and concerns. I believe there is a lack of planning and strategy. No. 2, I feel like there may be an unhealthy atmosphere for hospital employees. No. 3, An inadequate understanding of issues facing the hospital and an unwillingness of the board to challenge the chief executive officer about the strategic plan. Without immediate addressing of these concerns I know I am not doing an adequate job of protecting the interests of Grant County and GRMC. I really can't continue to be complicit in the actions of the board."
Trustee Jeannie Miller said she was glad to see Jaurique recognized for his service. "He no longer has to attend the Plant and Facility Committee meetings, and he probably thinks that's pretty cool."
Trustee Joel Schram said he wanted to expand on the financial outlook. "Although February may see a drop in volumes, overall the financial outlook is positive."
Board Chairman Mike Morones said he appreciates "Kelly stepping up to fill the interim CNO position and the hard work she is doing."
In reports and updates, Jennifer Yost, president of the GRMC Auxiliary said their numbers are up in January. "Our numbers of meals for patients in the Cancer Center are up. We are giving out receiving blankets to newborns. Our membership is down, but we have four new ones starting. We have received some of the stuff that has been requested, including a language cart. We had a very successful linen sale in January. Our tree in the lobby will change. We are going by holidays. We didn't take the Christmas tree down; we are just changing the decorations by season. We still have an issue with the clothes closet in the emergency room. People are just leaving items there, but according to policy we have to clean them and go through the Auxiliary to donate clothing. We also need more room, so that's an ongoing project."
Schram said in the Plant and Facility Committee they have discussed lockdowns and security issues. "Do you feel your staff is sufficiently trained for these lockdowns and security issues?"
"I think so," Yost said. "We made the front desk more secure."
Allen Townsend gave the Gila Regional Medical Center Foundation report. "We are at 15 members and want to increase it to help the community more. We're excited to see the changes being made. We have three new members. We have a couple of new things we're working on with Doug (Oakes, marketing director) to do advertising in Zia Magazine. We are getting pamphlets for meet and greets. These are in the preliminary stages. We are working on the golf tournament. We want to make it bigger. The number of golf carts is an issue. We created a Facebook page and got 100 hits and likes already. We are possibly going to do short videos for Facebook. Our honorary director is Howie Morales. We are also looking at including Rep. Rebecca Dow. We are looking for one non-voting trustee to be part of our group. We want to increase the foundation membership, so we need more volunteers."
Chief Executive Officer Taffy Aria presented her report. "I want to highlight that we have a full-time oncologist coming soon. He is in orientation, and he will arrive here in the next week or so."
Trustee Dr. Tsering Sherpa said Dr. Antonio Fontelonga has been available for on-call advisory services during his orientation.
Arias said a radiologic oncologist will continue to come once a week to Gila Regional Cancer Center.
Wilmot asked about a general surgeon that was being recruited. Arias said the woman had not accepted, but another offer has gone out to another general surgeon.
To a question from Miller about a gastroenterologist, Arias said the hospital is working to determine if there is enough call for one and what the volume is of patients being sent out for gastroenterological needs.
Rodriguez highlighted that she is talking to the directors of each department to find out what their focus areas are. She said Trey Donovan is the interim ER director. "And we are working on 53 different projects."
Miller said she was glad to see the report on reimagining care at the bedside.
"It involves interdisciplinary services," Rodriguez said. "What were opportunities are to be implemented. One of the projects we are doing this month is a pediatric care assessment."
Miller asked if Labor and Delivery were going to be moved to Pod 1.
Chief Financial Officer Richard Stokes said it would be a while, as estimates had to be gathered.
Morones asked about nurse recruiting.
"The passport nurses will hopefully start coming to us in March," Rodriguez said. "Our eight interns are doing their clinical rotations. If everything works out, we will have only one full-time nursing position open in the med-surg-ICU-emergency room area."
Stokes said: "I would like to make a comment on how Kelly is approaching this position. I've been impressed with her direct reporting. She is charging ahead with projects she has laid out."
Tanya Carroccio presented her Chief Quality Officer report. "I also want to comment to Kelly. I feel she has great communication and camaraderie with nursing to our risk management department on compliance and quality of care.
She said the hospital has started its leadership rounding program in the med surg unit. "I want to give kudos to Ramona Wilson and Juan from patient access. They pulled together a team and it's been going for about 2½ weeks. Patients have been responding favorably. We bring back the comments to the safety huddle. We are asking patients for names of those they have received great care from and we recognize them in the safety huddle and beyond. It's a nice way to show how great nurses are doing with patients. It's been best practice for a couple of decades, and it's come and gone here, but we want it to come and stay. We're working hard to make it a sustainable process, because it will make a big difference. Denice (Baird) is taking on the accountability for the program to see if we're making a difference. We are getting people trained on leadership rounding. Denice is sending out recognitions and hearing 'You made my day,' when they hear a patient was so satisfied with their care. All of our directors attend the safety huddle and, of course, senior management. Every morning we talk about safety."
Angelia Peyton, director of risk, is working on the review of charts. "We are already seeing the fruits of this review. Documentation is critical for care. We are so fortunate we have been given scholarships —Denice, Angie and I have received them, paid for by the New Mexico Hospital Association to do extensive certification. Denice and Angie have fellowships for quality, and I am taking the patient safety officer certification course."
She noted that records are all electronic now, "no more hanging boards on the ends of beds anymore. We have the software and it helps us see any gaps in documentation so we can address them."
Marketing Director Doug Oakes said the hospital has finalized the contracts for billboards, with two in Deming on I-10 and a double-decker, as well as one in Silver City. "We are talking about potential sites in Lordsburg and Catron County."
Miller asked if temporary signage could be placed over the door into the gym at the Billy Casper Wellness Center. She also asked for signage at the facilities across the street from the hospital.
Oakes said he was working on temporary signs, as well as permanent signage. He said the hospital may have to talk to the landowner across the street, as well as the city to get permission. "I don't have those answers yet."
"We're doing brand awareness," Oakes continued. "I know what the reach of the newspaper and of the Beat is. We're reaching a pretty high saturation point as far as the region and the radio. I'm confident our message is getting out, and we've got a pretty good frequency. We're doing TV, radio, print, outdoor, digital and social. I'm trying to balance how much we spend in each media. We're creating a brand awareness preference for our service lines. We're not doing lead generation yet."
Morones said, as a small business owner, he knows the key functions are operations, finance and marketing. "Marketing is sometimes the stepchild. We've had image issues here for a couple of years now. I appreciate what you're doing. I see that the way you're doing it is at a high level."
Chief of Staff Dr. Brian Robinson said the hospital is continuing to work on streamlining efficiencies. He said Dr. Norman Ratliff is now the head of the Continuing Medical Education Committee. "I appreciate what Kelly is doing. And Doug is a one-man army. I like that he is branding the people who work here. I want to touch on what Ed said. It's a process. In spite of our losses, we are continuing to work toward a positive outcome. You want to place it all on one position, but it takes time for people who have vision to get the processes in place. We have contracts in place, so I would say that's a positive that administration is trying to accomplish."
Delicia Dimberg said the hospital is shooting for accreditation with commendation. "That's our goal for the CME program. We have a survey coming up on the routine accreditation. We are planning education in the community and organizations targeted based on need. We are providing opportunities for hospital staff to get training."
Morones said a new report on the rules, regulations and bylaws reflects the desire of the committee to provide clarification and consistency especially for the medical staff.
Wilmot said when it was presented at the Medical Executive Committee, they found conflicts with other documents.
Morones asked that it be tabled. It could wait until the next meeting or be brought up again later in the present meeting.
Stokes presented his CFO report.
"We have complied with CMS (Centers for Medicare and Medicaid) to compare hospital pricing," Stokes said. "We have a lot of opportunities with our pricing."
The pricing list can be seen on the www.grmc.org site. Click Quick Links and then the link, Hospital Price List - https://hospitalpricelists.org/Gila-Medical-Center -under Pricing Information. It compares Gila Regional to market charges at Memorial Medical Center and Mountainview Regional Medical Center in Las Cruces, and to Mimbres Memorial Hospital in Deming.
For January, the hospital saw a $291,000 excess revenue over expenses. "We have a year-to-date profit of $3,035, compared to a $4.2 million loss last year. In EBIDA (earnings before interest, deductions and amortization), we spun off $529,000 for a year -to-date total of $1.6 million. That's a $3.3 million turnaround. In January, we had 46 days of cash on hand compared to 43 last year. We're still incurring costs that we are trying to mitigate. One is contract labor. We are working hard to get that out of the hospital. The average days of cash on hand in rural hospitals is around 30 to 35 days. We're still better than a lot of our peers. Things are better, but what we want the board and committees to know is that we still have a lot of opportunities. Almost every day, we find new opportunities. It's to the point where we should make a list to figure out which ones are going to work the best for us. Looking ahead to February, it's not shaping up to be a good month, but our cash collections are trending higher than we expected. Our cash collection is getting better."
Schram noted that the hospital could use more surgeries.
"We have two new surgeons coming, and we continue to recruit for the full complement of what this community can support," Stokes said. "We should receive the 2017 uncompensated care funding in March or April timeframe. We did a lot of work on vetting and validating that the numbers we have were true, both during the audit and ongoing right now."
Wilmot said he noted a lot of Meditech costs.
"Yes, we are looking at Experian Health for a patient access solution," Stokes replied. "It will cost about $85,000 one-time cost for us to implement.
We are working on the Meditech ambulatory system to consolidate all of our ambulatory operations on the Meditech platform. As we move the system forward, we have two electronic medical record systems that don't talk to one another, so we are pursuing more opportunities. When we get that solved, the software will also help us with the ancillary systems at the clinics. So, it's a way to consolidate all of our operations onto Meditech. Meditech also has a module for chemotherapy. We'll look at that later. Right now, we have some duplication. We have to get all the information into Meditech. These projects will have significant impacts on our operations."
Miller said from the patient point of view, when they come into the hospital all their information will be available so they can know how much it will cost and will provide information on them throughout their stay in the hospital.
Trustee Dr. Victor Nwachuku had a question. "You've improved collections. What are you going to do to improve from where we're at?"
"We have a whole list of projects we're working through," Stokes said. "We have our new clearinghouse Quadex. So, we're putting information into Quadex. There's a learning curve. We have reviewed all the edits in Quadex. Some things in there are not applicable to New Mexico. We've gone through and have pulled out all the unneeded ones. As we continue working in it, we will find new edits that need to be there. So, one of the things I'm working on is turning our attention to how our physician practice network is set up. It's set up primarily for billing and collections. But how it's currently set up, is that we received basically the lowest reimbursement we can get. It's been that way for years. But now that we are going through our contracts, we have partnered with HSI, a subdivision of the Hospital Association to manage our payer positions as well as how we're credentialing. We thought we were contracted with Blue Cross Medicare Advantage, but we're really not. So, we've been out of network, but we're going to fix that. We're looking at all of our providers and all of our contracts and that's not a two-week project. All of this will impact the cash coming into the organization. We are getting down to the basement on how things are structured and if it's structured correctly."
Once the trustees had copies of the rules and regulations, they pulled them back onto the table.
Dimberg said only the first page of the first section needed board approval. "The rest of the packet is just for your information."
Sherpa asked what the difference was. After a discussion, a motion was made to postpone the issue to the March meeting, giving the board members time to review the changes.
Next came board committee reports.
Morones said the Executive Committee developed the agenda. "As much as we appreciate Kelly, I want to give appreciation to all the staff for stepping up throughout the operation. It's a credit to the system work as a whole."
Miller presented the Quality Improvement Committee report. "The staff continues to monitor patient satisfaction, the occurrences of sepsis and C diff, as well as emergency room processes. In the culture of safety, everyone is committed to maintain the sustainability of safety throughout the facility. In May, the team did a survey of how staff thought about safety. Because of that survey, there is now a team with members from quality compliance, human resources, nursing, administration, medical staff services and risk management. We are reviewing the survey results and will identify key actions for implementation. One is the leadership rounding you heard about earlier. It consists of teams of two who go out every day. One of the team members is clinical with a non-clinical member. They bring back what they discover to the safety huddle. They are making sure there is communication back and forth. We want patients to feel important and cared about, such as when you go to a fine dining restaurant and the chef comes out to talk to you. We want the culture of safety to be hard-wired into everyone. The Studer Principles are commitment to excellence, measuring the important things, building a culture around service, developing leaders to develop people, focusing on employee engagement, individual accountability, aligning behaviors, goals and values."
She noted that mock joint commission surveys are being performed and the hospital is following up on items that needed to be addressed. "They are at 93 percent compliance on flu vaccine among staff members. That's because Tanya talks about pledges, and it’s a very dynamic committee."
Schram gave the Finance Committee report. "What is done in the Quality Improvement Committee translates to better collections. We are doing a lot of work in finance. We should get about $2.3 million in April for uncompensated care, which will hit the bottom line and help days of cash."
Stokes said he visited with the state Finance Authority. "My first year here has been quite the learning experience. I'm trying to lead by what the Finance Authority recommends. We do have a bill that was introduced on the issue for revenue bonds for the hospital. It is trying to access the cigarette fund for us to buy a PET scanner and to renovate the chemo mixing clean room. The legislation has been crafted to help us pull money out of the fund to pay the debt. Other legislation would allow the hospital to go in subsequent years without having to go through the Legislature to appropriate money. We would have to issue a revenue bond anyways, but if we could bundle that into a larger revenue, it would be at 2.3 percent interest."
Stokes said he was also reviewing the pension plan. "It's not our money, but we have the fiduciary responsibility. We will start the process of evaluating the different options. We will find several options."
Schram said to clarify: "Some of the Financial Authority duties are to make improvements to hospital equipment without the need to go to taxpayers. We are doing it through operations."
Stokes said if the bill goes through, the Hospital Funding Act requires that the County Commission approve it. "We are not close yet to asking the commissioners. It may be several months away."
Morones said the revenue for the bond would come from the Cigarette Stamp tax. Stokes said one pot of money is from the Cigarette Stamp Tax and another is from operations.
Several contracts came up for approval and were approved, most were for March 1, 2019 through Feb. 29, 2020. The professional services agreements included one for on-call specialty service coverage in orthopedic surgery with Roberto Carreon, MD; on-call specialty service coverage in ob/gyn with Michelle Diaz, MD; on-call specialty service coverage in anesthesia with Dennis Gutierrez-Vera, CRNA; on-call specialty service coverage in pediatrics with Gregory Koury, MD; on-call specialty service coverage for urology with Amos Lash, MD; on-call specialty service coverage for ob/gyn with Victor Nwachuku, MD; on-call specialty service coverage in general surgery with Okay Odocha, MD; on-call specialty service coverage in anesthesia with Aaron Rudd, CRNA; on-call specialty service coverage in critical care/pulmonary with Donald Stinar, MD; on-call specialty service coverage in general surgery with Frederick Wendler MD; and on-call specialty service coverage for anesthesia with Dan Zerger, CRNA.
The physician members agreements included an amendment for the Ongoing Physician Practice Evaluation with John Stanley, MD for Jan 1-Dec. 31; agreements for March 1, 2019 through Feb. 29, 2020 for OPPE with Tsering Sherpa, MD; for OPPE with William Neely, MD; and for OPPE with Preston Maxim, MD.
An employed physician agreement was approved for Dr. Stanley and an employed nurse practitioner agreement with Cynthia Moreno, NP.
For the Plant and Facility Committee, Miller presented the report. She said the hospital has new codes, and each employee has a list of the codes as a badge buddy on the back of their ID badges.
She said staff met with the town of Silver City, Grant County, state officials and the Detention Center to make a decision not to tolerate violence in the community. "Silver City will do increasing parking lot patrols and tours of the hospital. Signage will also be put several places. We are waiting to hear about the software leasing, and a FEMA three-day workshop will take place at Western New Mexico University in March. I sent a request to attend, because that's one of my favorite topics. But it is during board week, so there will be meetings."
Morones noted the Human Resources Committee meets quarterly, and the dashboard isn't updated. "The next meeting is in April, but I think we should have a discussion on whether to monthly update the dashboard."
Miller asked if contract labor on the dashboard refers to physicians' contracts, too. Arias said it did not.
Nwachuku noted that the cost of travelers has gone down. "That's good."
The Board Bylaws Committee did not meet in February.
Board members took a short break before an executive session.