[Editor's Note: The Board of Trustees held a long meeting on May 31, 2019. This is the second and final report of the meeting and covers most of the administrative and committee reports.]
By Mary Alice Murphy
After the several presentations as part of Chief Executive Officer Taffy Arias' report, the next article covers the rest of the administrators' monthly reports.
The CEO report can be read at: http://www.grantcountybeat.com/news/news-articles/51540-grmc-holds-board-of-trustees-meeting-053119
Following the conclusion of the reports from five hospital department directors, Trustee Tony Trujillo made the observation: "We get criticized for not holding our CEO accountable. We do hold her accountable, and this is an example of what she does best and that's that she hires the best quality people. There's a saying about CEOs. They live and die by the people they surround themselves with. She chooses the best. She'll be around a long time."
Interim Chief Nursing Officer Kelly Rodriguez said 11 of the 12 international nurses that "we hired in our first go-round are here. Two more will do their onboard training next week. We have made offers to three additional nurses. Three of their spouses would like to work at the facility, too." They have experience in items such as security and facilities.
She said the Baby Friendly redesignation for the hospital has been submitted, and the hospital should hear back within the next couple of weeks.
"As we close our 2018 nurse internship group, we are still working with the 2019 interns. We are changing the branding to nursing residency program. Additionally, I hope we will have statistics available for you for our sleep lab to let you know how it is doing. I'm also going to add to my report staff recognition to point out some of our key staff. One is Winn Burns, who works in multiple areas, and Rachel Benavidez, who is our Cancer Center patient navigator. She and Burns go above and beyond what is expected of them."
Arias said the new CNO, Rose Lopez, will begin June 19. "I publicly want to thank Kelly for the unbelievable job she has done as interim." The room gave Rodriguez a standing ovation.
Trustee Jeannie Miller asked about Pod 1. Rodriguez explained that two to three years ago, the hospital had two med surg units. Med Surg one was primarily post-operative and post-partum. "We closed it, Pod 1, and merged it with med surg 2. We have some opportunities, so our goal is to move some of the labor and delivery patients into med surg 1. I talked to the state just this morning, and I have yet to report to Taffy and Richard. In addition, we have an area that has not been used by our present organization. I call it Pod 4. It has five beds. That would be our optimal place for our ortho patients. We want to separate our medical patients, who sometimes have infectious diseases, from our surgical patients. Pod 2 is where all our medical patients are currently admitted to."
Chief Quality Officer Tanya Carrasco said she had a couple of things to highlight in her report. "Things are always happening in quality. In alignment with our mission of high-quality care and exceptional patient safety, GRMC made the decision to purchase the quality and risk management module. It is moving along. I commend the team for keeping going with a major resource leaving. In mid-June, we will start training. Right now, all events are placid in applications in MedTech. Right now, we have paper and computer. We want them all in one place, so we can tackle them in real time. The quality module will provide current data and also help us address them in real time."
She said they had a slight delay in starting telemedicine for behavioral health and stroke and neuro programs. "The delay is necessary because it is around our credentialing. Medical staff services brought it to our attention. The group we are going to work with didn't have the ability to do proxy credentialing, so we are going back to traditional credentialing, which will probably move implementation to August. The company we are working with has all their physicians credentialed, but they didn't want to give us their primary documents. We want proof, so we'll do it our way, because we need to credential to the highest standards."
Delicia Dimberg, medical staff services director, said: "We do it anyway. We didn't want to take their word that they did it."
"So, we're credentialing telemedicine the way we do it," Carrasco confirmed. "We may do stroke and urgent care in the clinics later. This gives us time for educating everyone involved."
Trustee Joel Schram said he heard on the news that there had been an increase in measles cases with the influx of migrants.
"We've heard of one case in New Mexico and it didn't come in with any migrants," Carrasco said.
Doug Oakes gave his marketing director report. To a question about updating the website, he said he can make updates to the website through Scorpion. "We are evaluating a website redesign. We want it to be ADA compliant, and I would like to see it be cleaner, with better branding."
He said the hospital has been advertising lymphedema and getting return on investment on the advertising. "We are building robust marketing on all our services. We keep hearing anecdotally how much people like the articles in the paper and want them to continue. Kathy Lyn Pacheco is doing a fantastic job of recruitment."
Trujillo said Oakes was out working the Tour of the Gila at the Saturday Downtown Criterium. "I've heard Zia Magazine has an article on our CEO, although I haven't seen it yet. It's great work you're doing."
Miller asked where recruitment was happening on social media.
"We're using Facebook and LinkedIn," Oakes replied. "LinkedIn can be costly as it's by the click."
Miller said she was a big proponent of marketing. "I appreciate your high-quality ads, and the layouts and logo."
"We have high-quality people," Oakes said. "These ads are going to help our hospital. Size matters. Billboards bring in people."
Miller asked Rennie Mariscal, clinics director, about the planned clinic in Deming.
Mariscal said some procedures can be done in the office. "We will have nurse practitioners and physicians rotating into the clinic. We have contracts with other providers of lab work and such in Deming or we can do a referral. It's the patient's choice."
Chief Financial Officer Richard Stokes said Memorial Medical Center out of Las Cruces will have a presence in Deming. "It's a strategic move for us."
Arias said: "It's all about service to our patients."
Stokes said the hospital plans to rotate specialists to the clinic, too.
He then gave the financial report for April 2019. "We had a $60,314 profit, as compared to a loss of $327,000 last year. April last year, we had a high EBIDA (earnings before interest, deductions and amortization), but that was because it was the month we received the safety-net care pool check. Our EBIDA this year for April was $295,305. Our collections are still around 30%, but our cash to net revenue was 124%. We expect cash collections to start to exceed 30%."
"We received a letter from CMS related to our decreasing volumes of inpatients," Stokes said. "For 2015, we can expect $640,000 in reimbursement and $1.6 million for 2016. We have submitted 2017 and 2018, but we are waiting to hear if they are accepted."
He said he has spent a lot of time in the past month going through the balance sheets, "making sure they are what was reflected. Gila Regional has had the habit of lumping things into one account. My goal is to submit to our external auditor by the first of August, the balance sheet and accompanying documents, so they know what's in the accounts and why."
Stokes said "our accrued PTO stands at about $1.5 million—one of the larger accounts on the liability sheet. Where in the payroll is a report on each staff member's PTO (paid time off?)? So, I had to figure out how to show that number. I've got that squared away and I'm teaching Kelly (staff accountant) about that. We know now how to get the detail on accounts payable."
Trustee Ed Wilmot asked: "So, historically you didn't have the detail in the balance sheets and now you are doing it? Wow."
Stokes said he had accounts from years ago, where there was a debit and a credit and they netted out, but "why were they on the balance sheet to begin with? What is a more interesting issue I had to deal with was the way the system was set up years ago. For instance, the revenue in from one company in a physician's practice and the expenses in the hospital company. There were due tos and froms for the physician and the hospital. They almost matched, but not quite. There was no expectation that either the physician or the hospital was going to write checks. It was simply an accounting method that wasn't watched as closely as it should have been. The only way to get rid of it was to do an equity transfer through the hospital and between it and the other company, which was the physician's practice. We've made that entry, so now you'll see the equity on each company, and when you consolidate them, they net to zero. We've cleaned up stuff like that. As I have made these entries, I have called Tom Dingus (external auditor) and explained everything, so when he comes here at the end of August, he won't have questions about these entries. We will finish the balance-sheet clean up this month."
At the Finance Committee, "we went over the capital and operating budget for next year. I want to let the board know that the system controller, Jennifer, starts next week. The controller should be the successor to the CFO. I will be training her to that effect. I have also hired a patient financial services director, Wanda Turnow. She comes from a hospital in Tennessee and has served for 20 years in both non-profit and profit organizations. I spent about 40 minutes speaking with her former CFO, who has separated from the hospital about three weeks ago. I had a nice conversation with him, so I feel comfortable on what Wanda will be doing. I also talked to her and she could answer all my questions and tell me what to look for or watch out for."
Stokes gave an update on the rural health clinic designation. "We have engaged with Community Hospital Corp. out of Plano, Texas, to navigate the process. Rennie (Mariscal) is leading this project. The company said it was almost like pulling teeth to get hospitals to respond quickly. The representative I talked to said he had never had a hospital that had engaged with them before who had gotten the information to him before the deadline. Kudos to Rennie and his team."
"We have also engaged CHC to do an evaluation on critical access," Stokes continued. "We're going to start that process. I have already gotten the road paved to access the information. They said that Gila Regional had provided the information for the RHC so quickly, they were confident they could get the critical access piece done quickly."
On page 2 of his report, cash collections were $4.89 million versus $4.92 million last year. And that was without the safety-net care pool coming in. "I want to give the board a heads up. Today, our days of cash on hand is a little over 20 days. We had three payrolls this month, basically the first day of the month and the last day of the month and one in between, so we had three cash outlays for the month. When I started looking at accounts payable, we've set a new process in place. We are going to standardize the day we write checks and it will be Fridays. We are going to look at invoice and due dates on Thursday and we will tighten up those that we pay a little bit quick. We will concentrate on the due date. We will try to manage our cash a little better there."
As an operational point, the finance committee requested a process giving the Board chairman a heads up "anytime we get below a certain level of days of cash on hand. We set the day on the Monday before the meeting if the level falls below 30 days. To Mr. Schram's point, knowing and doing is two different things. So, we are really looking hard at what's driving cash expenditures. We have already taken steps to cut cash expenditures in certain places. Cash has been on a slow downward trajectory over the past few years. My job is how to figure out the best way to manage cash."
Chairman Mike Morones said in looking at accounts payable, he noticed that the organization spent about 10 or 11 days of cash paying down accounts payable. "We want to keep out cash on hand at 30 days or above. We need to work on how the cash is managed. We dropped 10 days for things that were due 20 days out. Twice a year, you have three payrolls in a month."
"I have lots of things going on," Stokes agreed. "Part of the board's responsibility is if they see something squirrely, come see me."
Wilmot noted that the number of days of cash on hand needed to be communicated to the County Commission, because they were surprised. "An early phone call would have nipped that in the bud."
"We notify the board chairman first as the conduit to the Commission," Arias said. "It needs to be a streamlined process, so we don't have misinformation going to the commissioners."
Morones said the finance committee has talked about how the volatility of health care was masked by state and federal subsidies, so they masked issues. "No one was asking questions, because they were so comfortable. We have to relearn a new streamlined way to communicate. We will continue to work hard at better communications at all levels."
Miller said she was glad the hospital was going with a contractor on the RHC and the critical access, "because you guys don't have time."
"We made it clear to CHC, we want a map we can duplicate," Stokes said. "They said good for you for wanting to do it yourself. That was six weeks ago before the safety-net care pool change, when I wasn't sure that critical access was the right choice. I'm still not convinced. We need a good picture of what critical access looks like. It's very hard to undo. This will be a decision for at least a decade."
Trujillo said the board needs to have its selling points and needs to completely understand the issues about the hospital. "We need to make sure the community understands the critical access status. What is the safety-net care pool status?"
Stokes said the hospital has heard nothing new. "We're still waiting on the impact it will have on the disproportionate share of Medicaid. We are looking at 2020 and 2021, I'll be bringing to the board some new policies that need to be enacted before the end of June. They will impact our 2020 safety-net care pool. The state has said it will phase in the process, but we don't know what that will look like transitioning from the safety-net care pool over to the S-10 reporting process on Medicare. We have to make sure we have the data for the S-10, because what's on the S-10 now matters. It didn't before, but we're on it."
Chief of Staff Dr. Brian Robinson said: "We have 146 people on medical staff, mostly in teleradiology? I'm a non-voting member and I don't get access to all this information." After much bantering, he will get the information, but the list includes everyone with hospital privileges.
"We are having staffing issues on the OPPE (ongoing professional practice evaluation) Committee, but we are dealing with them," Robinson said the Bylaws Committee will meet in June. "We are continuing to update policies. The CME (continuing medical education) team got accredited."
Dimberg said the OPPE needs a quality analyst, because the other peer-review coordinator retired.
Robinson asked for approval of the medical staff services policy.
Wilmot asked why the list was sequential. Dimberg said it was just the process she went through. "This one went only to the MEC (medical executive committee) and now to the board for approval. Henceforth, I can do a cover sheet to show where it has gone for approval."
The policy was approved.
Next came board committee reports.
Morones said the Executive Committee met and some items will be discussed in the executive session.
Miller said the Quality Improvement Committee is working on staff issues. The graphs show things are starting to climb in quality. "A lot of stuff is going on in the hospital. The Gila Healthy, Gila Proud initiative, the Just Culture —a number of initiatives. I think we as a board should know about these programs and we should support them and get the message back to staff that we know about them and support them. Something like a notes from the board to the staff or something. It's important for the board to have the information about the initiatives."
Schram noted that at the bank, they share items for employees.
Oakes said emails are tough with Outlook and its protocols. "Anything we do should be total text maybe a letter from the chairman. I ask each month for content from the directors, and I could add the board to it."
Morones said it would be important to create a culture with a single person regularly doing it.
"We hear stuff in the committees," Miller said. "It's a good place to start developing messages. One of us should take this on, but it has to go through the Executive Committee."
Arias said: "We will put something together for next month."
Miller said the QIC reviewed the risk management plan. "It will come back to the QIC to approve and we will bring it to the Board."
Morones said the QIC is a really important committee. "We can't take our eye off the quality ball."
Wilmot said there is such a breadth of activity in the Quality Department. "Do you have the skill set and breadth to perform it all?"
Carrasco said: "Yes, but we also have risk counsel we can turn to and run it through. We didn't have a director of risk for a while. We continually address it. We could also use a risk quality coordinator."
Miller said there is a lot of focus on succession. "It's critical for when someone leaves."
Arias said to Wilmot: "It’s a point that Tanya can vouch for. The department was organized quite differently before. We have increased the number of full-time employees with skills for what the department requires."
Schram presented the Finance Committee report. "Mr. Stokes addressed most of what we discussed. Every item in the balance sheet need to be supported by ledgers of details. We also have three contracts to approve."
The first contract approved was an agreement with Dr. Robinson to serve as the chair of the Utilization Review Committee, "to make sure cases are done right."
Dr. Norman Ratliff was approved to serve as the CME committee chair.
Dimberg noted that the requirement was for the chair to be a physician.
The fourth amendment six-month extension to the physician services agreement for the Emergency Department to Innova Emergency Medical Associates, P.C., was approved.
"When I first came, I was astounded by the level of commitment to our hospital in the physicians I've seen step into these volunteer roles," Arias said. "It's wonderful."
The Plant and Facility Committee report indicated the committee is waiting for a report from Facilities. "We spent time on proposed capital improvements, but made no recommendations," Miller said.
The Human Resources Committee did not meet but has an evolving report on the dashboard of members' packets.
Arias noted the amount for human resources will be "going down by $300,000 soon" with the completion of contracts.
Miller said the report needed to be make clearer that the amounts reported were not just for traveling nurses but included other contracts.
The Bylaws Committee did not meet.
Board members, after a short break, went into executive session.