Financials are looking good.
[Editor's Note: This is part 2 and the final of a two-part series of articles on the Gila Regional Medical Center Board of Trustees meeting on July 26, 2019.]
By Mary Alice Murphy
The recognitions and the Chief Executive Officer Taffy Arias report, which consisted of director's reports can be read at http://www.grantcountybeat.com/news/news-articles/52405-grmc-board-of-trustees-hears-from-several-directors-during-ceo-report-072619
Chief Nursing Officer Rose Lopez said she is working with a lot of programs, in the community and in the hospital. "Our priority is recruitment, in collaboration with the WNMU (Western New Mexico University) Nursing Department. I have met with the instructors. We are their only exposure to clinical work. Twelve Level 3 students will be exposed to our hospital, and we will try to convince them to become staff. I’m also involving them with our in-house education partner."
She talked about rounding. "The nurse, the directors, should see the patient every hour. What we are doing is evidence-based. It reduces falls, it makes them have good camaraderie with the patient, and the family will feel that they can always call for help. They should also thank the family for using Gila Regional. We are working on the American Health Association immediate action program for stroke, with the ER physicians and nurses to prevent further damage, and hopefully with the tele-neurology physicians when they come online."
Miller asked if hourly rounding was replacing leadership rounding, to which Lopez replied that they work in conjunction.
"Stroke is hard for the emergency department to handle," Miller said.
Kelly Rodriguez, former interim chief nursing officer, said any provider can assess the situation. Usually a head CT is done, the caregiver looks at the patient's response and the physician accepts or rejects a transfer. "When we get the tele-neurology set up, the physician can set eyes on the patient to better assess."
Lopez said prior to having the tele-neurology, even talking to a larger hospital, they may not have neurological services. "Once we have it, the physician can assess the situation and will give us a better chance to keep the patient here."
"If the patient is not bleeding and not prone to bleeding, we can start giving a medication that can prevent the blocks to increase oxygenation to the brain," Lopez said. "Some will come in and verbalize their symptoms that sometimes may mimic hypoglycemia. Most are not very aware of the stroke symptoms."
Arias said the Fast Track program the hospital is building in the Emergency Department "is for lower level symptomology like the sniffles, for instance. It's a time issue, not a payment issue, low severity and rapid turnaround to debulk the department to concentrate on the higher level of need."
She said everyone who comes through the emergency department goes through triage and must have medical screening.
Wilmot asked how many strokes come into the hospital. Lopez said she can't say there are a lot because most are being transferred right away.
"As we get this program underway, what we will need is massive communication," Arias said. "We have to get people to have regular screening. Some don't know if they have hypertension. But before we do the marketing, we have to get the program in place. It all starts in family medicine."
The hospital is working on how long patients are held in the ER. "The national median is 127 minutes," Lopez said. "We're at 168 minutes, so we're trying to get it down. We're working on risk and event reporting and developing processes to avoid errors. We're trying to prevent pressure ulcers by teaching them how to float the patient, not in a magical way," she said to laughter.
Trustee Dr. Victor Nwachuku said he was happy to hear that she has identified points of concern for him. "I'm glad you're educating nurses, so they know when they have committed an error. That is an important one you have identified. I've seen nurses spending more time on computers. They have to document and make sure that the information is correct, rather than taking care of patients. It is also beneficial to get them taking care of the patients."
"We are doing a pilot program in the OB area," Lopez said. "They are working on the computers that have been in the walls, but not used, so they are spending more time with the patient and on the computer."
Nwachuku said the issue with the time spent in the ER is an ongoing issue. "I've had patients go to the ER, not get seen quickly, get frustrated and leave. Ways to resolve that will be very good."
Chief Financial Officer Richard Stokes thanked Wilmot for his good question. "We know that the national stroke incidence will increase by 26 percent by 2030. It's a coming wave of issues to all hospitals."
Miller said that with TIAs (Transient Ischemic Attacks), by the time the person gets to the hospital, they're gone.
"We are making progress identifying these patients," Lopez said. "We have new guidelines to look at the cholesterol and blood pressure, in an overall 360 program."
Miller asked if a person comes into the emergency department and says they have had a TIA, but it may be gone, "do we contact their primary physician?"
"We encourage them to go to their primary," Rodriguez said.
Denice Baird gave the report in place of Chief Quality Officer Tanya Carrasco, who was absent. She talked about the surveillance module.
"It looks at vital signs and alerts the caregiver to potential problems, such as sepsis," Baird said. "We can then put pieces in place to save a person's life. We're excited about that. It helps us with certain events such as restraint or seclusion to make sure we are keeping the patient safe. We will start the validating testing and hope to have it in place in the next couple of months. We will have the policy module training next week. It is a robust program."
She said she and Carrasco had attended a workshop in preparation for credentialing. "Tanya expects to sit for quality credentialing next month. I will probably be ready in December a year from now."
Baird said Chris Chavez is working on the safety of "our environment. He has gotten approval for two new personnel working to get more cameras in the behavioral health unit, as well as increased security in the maternal and child area. He is also working on systems and compliance in the departments."
She noted that in the recent Joint Commission assessment of the hospital, the highest number of citations was in environmental care, and Chavez is working to address the citations.
Marketing Director Doug Oakes said his report was in the packet and he stood for questions. "We now have ad assets that we can implement over a year that we will run as often as possible. It enables us to have powerful advertising. An ad should run at least three times to make an impact."
Arias said: "It not only emphasizes the technical and skill level of our care, it also emphasizes our compassion. It's a great campaign."
Oakes said it came out of patient and staff comments. "What sets us apart is our quality of care and compassion. We are presenting the caregivers as heroic in what they are doing and that they deliver with compassion. We have a really good care, but also the compassion I saw with Dr. Robinson when he took care of my daughter when she broke her arm. He explained everything, and he did it with compassion."
Miller asked about where the marketing is for the Deming Clinic.
"We've been advertising heavily for the grand opening, and we had a good turnout," Oakes said. "We had members of the public who were looking for a new primary care clinic. Businesses were there, and the chamber was very helpful. We have a bank of assets to market throughout the year. They are targeted ads. We will keep repeating our quality of care and compassion."
Kathy-Lyn Pacheco, recruitment, said: "Doug has helped me with social media, as well as with a banner that I will take to the conference I will be attending."
Stokes presented his Chief Financial Officer report.
"This is the end of fiscal year 2019 report," he said. "We show the month-to-date as having a $4.2 million profit. But that's not a real profit. It reflects the accounts receivable and accounts payable clean up. We jammed everything into June to get it into fiscal year 2019. I want to focus on the year-to-date numbers. We are making sure the balance sheet is current and that we can substantiate the years of neglect that we have fixed in one year. FY 2019 was get in and clean up stuff. That was a big project and it has been going all year. We got it all together, so that as we get into fiscal year 2020, we are looking ahead, not behind."
He commended Comptroller Jennifer Klotz, because since her arrival, she has been making sure to map and correct the numbers. "Our efforts came to fruition in June, when it all came together. The actual profit for the year-to-date is $299,402. Without the cleanup, it would have been about $100,000. The first eight months I was here we were dealing with whether the hospital was going to stay or be sold. This fiscal year, we have concentrated on getting the books clean."
He also commended Wanda Charnock, who has only been at the hospital for 30 days. "These young gals know by looking at a number, if it looks right. When it doesn't Jennifer can go in and fix it."
Stokes said the EBIDA (earnings before interest, depreciation and amortization) year to date was $3.12 million. " Last year we had about $4 million more in reimbursement than this year. Losing $9 million that we would have received from the safety net care pool, if the program hadn't changed, was a huge hill to overcome and we did. We need to get to the point where we don't have to rely on supplemental payments from government entities to survive. That should be cream on top of the cake, so to speak."
"In FY 2020, we are looking at cash optimization processes, at cost containment and at increasing operational efficiency across departments," Stokes said. "Fiscal year 2019 will allow us to spring into 2020 looking forward. The external auditor will be here Aug. 26. I've kept our auditor Tom Dinguss informed about what we're doing and why we're doing it. "
Stokes cited cash collections at 32 percent. "I'm not satisfied but we're going to put a lot of attention on that. We had 112 percent cash to net revenue in June. While all of this is going on, we were informed that our 2016 Medicaid disproportionate program payment was being audited by Myers and Stauffer on behalf of the state. We are so fortunate that we have such skilled people here. One lady that works in our information technology area, Barbara Dowdy; she is really sharp. Brett Gobel is a New Mexico expert on this program. He told me the other day he has worked with a lot of hospitals and there are none who come up to the level of Barbara to extract the appropriate data. We submitted the report data to Myers and Stauffer yesterday (July 25). The outcome of this effort was that we were underpaid by $5 million. The good news is that we are not in a payback situation. If the state determines that other hospitals were overpaid and if they can recoup that money, they will re-distribute it. We try really hard to submit the right data that will affect this hospital in 2022. A lot of work went into the balance sheet clean up. We gave the Financial Committee an update on the Rural Health Clinic status, which will affect our Family Clinic. The benefit may be around $400,000. We have the kick off call on Monday to go to the layout step to move to critical access. We received the preliminary critical access study and got more data. This is more in depth than the high-level data we had received. We will receive $2.59 million for the Cancer Center project along with the $880,000 direct loan from the Finance Authority. I met with the bonding attorney, who is also the county bonding attorney. He's a Silver City boy, Luis Carrasco. We received the completed agreement for the capital outlay from the state for our roof. We will talk in the Plant and Facility Committee on how to address it."
He said the good news is that the state has agreed to reformulate the 2019 safety net care pool to small hospitals, and the end result is that GRMC will receive a $2.6 million reimbursement, half in October and half in January. "All the hospitals have agreed to it. It's pretty much a done deal. On the Medicare decreasing volume, we quality for $2.3 million, which has been pushed back to October. October should be a good month."
Miller asked what the target days in accounts payable is.
"My goal for cash on hand is 100 days," Stokes said, "and around 30 days in accounts payable. We have to improve our billing and collections. The whole point is to manage AP for cash. Jennifer is working on having the invoices so we know if they're accurate."
In another move, Stokes said the hospital has to pass a banking resolution to remove Mike Morones as the board chairman and replace him with Trujillo. "It allows us some flexibility for manual check signing."
He said the hospital will start the Rural Health Clinic process for the pediatric and Deming clinics. He said a cost report would estimate the cost, which would be settled up at the end of the year."
Nwachuku asked about critical access. "Have you come to the conclusion that we should do it?"
Stokes said he would have a better answer on Monday. "The preliminary report looks good."
Morones noted that two or three years ago, a 30 percent collection rate looked unreachable. "Now Stokes isn't happy and wants more. It explains why we haven't sunk in spite of losing the $9 million in safety net care pool funding."
Stokes said nobody in New Mexico knows what the safety net care pool will look like after it partially goes away in 2020. "We are taking steps on what we do know, to position ourselves. I suspect it will be a hybrid of S10 and the safety net care pool, and we can go back and refile for 2017 and 2018. The blended format will be based on 2018 data. If I get it right this year, then in 2022, it will be what it is."
Arias said the couple of years the hospital has spent in cleaning up the books, "we've been devastatingly shocked at what we've found. The hospital went through a period of not paying vendors. We didn't know we owed money to them. It's shocking for a business. We have to clean up and build the business at the same time. At some period of time, everything will work the way it should. I'm very proud of Richard and his efforts and the Finance Department. That's why we're still here today."
Stokes said the year-to-day profit of $299,000 compares to a loss of $1.8 million last year. "That's really a swing."
The banking resolution for signature authority was approved.
Schram said the thorn used to be Meditech. "Now we're seeing the positive results from it turning it into a positive. We are taking the bull by the horns and riding onward to ensure the sustainability of the hospital."
Chief of Staff Brian Robinson said he would like to receive the packet of anything he needs to be engaged with.
"The Medical Executive Committee is working on compliance for vaccinations for staff," Robinson reported. "The OPPE Committee (ongoing professional practice evaluation) has a new system. The Bylaws Committee is developing a section for summary suspension policies and procedures."
The Executive Committee, according to Trujillo, learned what it needed to do from the Vice Chairman, Dr. Nwachuku.
Miller said the Quality Improvement Committee did not meet in July.
Schram reported on the Finance Committee. "Richard pretty much covered what we talked about. In executive session, we will talk about insurance adjustments."
Trustees approved a credentialing agreement for the Telemedicine Radiologist at Direct Radiology LLC. They also approved a professional services agreement for radiology interpretation for Dr. Richard R. Black; an amendment to nurse practitioner employment agreement with Michael L Harris, FNP-C; an amendment to a nurse practitioner employment agreement with Edla J. Rucker, FNP-C; an on-call specialty service agreement for EKG interpretation with privileged providers, including, but not limited to Norman Raliff, M.D. and Donna Kiehne, FNP-C.
The Plant and Facility Committee did not meet. Its next meeting is in August.
Morones presented the Human Resources dashboard. "We had a good meeting, which revolved around this dashboard. We spent a lot of time on exit interviews, which were more favorable than I anticipated."
Trujillo asked for input on selections of members for committees.
Before the executive session, Stokes said the hospital may receive about $4.6 million in October. "It is expected, but not guaranteed. We got an enhanced payment, but we are still not getting what we anticipated. The Small Hospital Group spoke up to the governor and the Human Services Department. They listened. Two weeks ago, the hybrid method was accepted, and they are formatting how to disburse the funding."