[Editor's Note: This is final part of a two-part series on the GRMC Board of Trustees meeting on Friday, June 29, 2018.]
By Mary Alice Murphy
At the Friday, June 29, 2018 regular Gila Regional Board of Trustees meeting, the first report was given by out-going Auxiliary President Frances Day. "I'd like to thank all of you for your support of the auxiliary and of your service to Gila Regional. Reporters, you are in my heart because of the tragedy in Maryland. We thank you for the work you do to cover the community."
"This is my swan song," Day said. "I won't be going anywhere, but my role will change. We have 72 members."
Gila Regional Chief Executive Officer Taffy Arias said: "We thank you for everything you've done for the hospital. You're a bulldog at getting things resolved."
During her CEO report, Arias said the report has many components. "We are still looking at the footprint expansion of Family Medicine. As soon as we know what our status is, we will go into a contract to rent a place and expand to Deming and later to Lordsburg. We have two family practice physicians ready to serve, but they are waiting to know what will happen. In cardiology, Dr. Ratliff is working on a cardiac rehab program with a new director which we have hired. We will increase pulmonology, in accord with our 2019 strategic plan, with Dr. Stinar actively engaged with nursing. We will have respiratory rehab. That is very exciting. A pediatrician who was really wanting to come to this area, but his wife is pregnant. He is leaving an area of uncertainty and didn't want to get involved in another area of uncertainty. He has chosen not to come, but we will keep recruiting. In our surgical nursing, we have had a change of our perioperative director. We have an interim and she is doing an outstanding job. She, anesthesia and nursing are focused on improving efficiencies and surgical volumes. We have made an offer to a general vascular surgeon, with excellent credentials, who has completed his pre-application and application and is putting in for New Mexico licensure. On our Cancer Center operation everything is going very well. We had an offer out for a full-time oncologist, who was interested, but he has moved on because of the uncertainty. Two others who are interested are coming for interviews. Radiation therapy is up and running. PET scans were every Monday; now they are every Thursday. We successfully completed the Joint Commission accreditation process, thanks especially to nursing. The health care community participated in a Las Cruces golf tournament and then in the Gila Regional Foundation golf tournament. It was successful at raising about $17,000."
Trustee Tony Trujillo commended First American Bank for being a sponsor. Trustee Joel Schram is the market president for the local branches of the bank. "The best golfer was Taffy, with only two clubs,"
Doug Oakes, marketing director, said the foundation had done a great job. "It was an extremely successful tournament. People thought it was great. The money goes directly to scholarships and equipment that the hospital needs. They, like you trustees, are doing it voluntarily."
Arias said the hospital welcomes having the foundation back under it.
Trujillo announced that the Interim Legislative Health and Human Services Committee would be meeting in Silver City on July 9, 10 and 11. "It's a great opportunity for us to tell our story. Taffy was on the agenda, but last time I looked she had been taken off."
"I put myself back on," Arias said.
Trustee Jeannie Miller asked about the schedule for Dr. Tarnower at the Cancer Center. "I understand she will not be coming here after September."
"We're working on that," Arias said. "Dr. Rabinowitz is maxxed out."
Trustee Chairman Jeremiah Garcia commended the trustees for their response to the Joint Commission.
"The participation of the board was critical," Chief Financial Officer Richard Stokes said. "It was well noted by the Joint Commission."
Chief Nursing Officer Peggy White highlighted the progress in the Emergency Department. "We are right on target progressing on the Fast Track and flow of the department. We are taking a strong focus on travelers. We have 13, but we have plans to decrease that number."
Schram asked how the hospital is doing at retaining nurses.
"We will offer raises to bedside nurses who deal with acute care," White said. "Several were in tears when they were notified. Several said they had planned to leave, but now would stay."
White noted that on July 9, the internship program would start up again. "It's a great recruiting tool."
Arias said the raises for the bedside nurses was a strategic move. "It was no knee-jerk reaction. We did an analysis and made it fair to all full-time and part-time nurses. We wanted to be sensitive. We wanted to retain the experienced nurses and bring in more experienced nurses. We will increase the beginning pay, the median and maximum pay. It will put us in a better position to recruit. It will cost us about $600,000 a year, about $47,000 a month. We had to make sure we were fiscally sound first. We felt we were in a good place to make adjustments. In the past, we've increased everyone, but this time, we gave the increase to the acute-care nurses. It will help alleviate the price tag of travelers."
Stokes agreed that there would be an increase in costs to the hospital. "However, if we successfully fill all the open positions and remove the travelers, we will be at a better-than-break-even from the dollar perspective. So, from the financial perspective, it makes a ton of sense."
"It's all strategically implemented," Arias said.
Trujillo congratulated them for taking the issue on, as the board and administration had recognized for a long time that the nursing salaries needed to be adjusted upward. "You've done it the right way. Thank you for the great news."
Miller asked White about the process of notifying Silver Health Care of the high number of their patients being seen in the emergency department.
"When we have patients come into the emergency department frequently and repeatedly, it negatively can impact our scores and financially and even with penalties," White said. "In 2019, the penalties will be expanded to the PCPs (primary care physicians), because patients coming to the ER repeatedly means their plan of care needs to be addressed. The transition team will reach out to the PCP to allow the patient, who has come back with the same complaint, to get an appointment sooner rather than coming back to the ER. The most vulnerable time for a patient who has been discharged, so if they are scared they come back to the ER. Sometimes, the patient lists a primary care physician that they haven't seen in a year or ever. We are cleaning up the process. We are already seeing significant decreases in re-admission."
Miller said the strategic plan has the hospital reaching out into the community and working closer with the clinics. "Keep us posted on that."
Garcia asked for an update on the single bed rooms.
"Except for one night when we had to double up a room, we have maintained the single-patient rooms," White said. "We are seeing a positive impact on our HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), which comes from the surveys the patients fill out. The patients, the physicians and the staff love the private rooms."
The Chief Quality Officer Tanya Carroccio presented her report encompassing risk management, corporate compliance, regulatory compliance and quality, and "the items we are focusing as priorities across those areas. We let the accreditation team know we were focusing on the FMEA (failure mode and effect analysis), so we would not have a finding on that. They recommended we focus on that, which we did. We are breaking down the whole event reporting process to recognize the specific event and whether it was patient or environment caused. We find the trends, evaluate and fix them. Currently it’s on paper, but we are tightening the process we have now. It was recommended we hire a risk manager, which we have done. We had one with a great deal of experience accept the position and will start in August. We figure it will take several months of work, but it is one of our higher priorities. We are also revamping the contract process to close gaps that we have identified. We are looking at forms and policy management and how to tighten up that process, so things are updated."
She reported the recent survey had a 65 percent participation rate. She recognized Denise Baird as a great asset in getting people to fill it out. "We will analyze the data and create a report."
Miller said she liked the format Carroccio had used. "With someone dedicated to risk management, I have a problem with siloes in organizations. It looks like you're breaking them down and pulling in people who need to be pulled in."
Carroccio said the contract process will be across the board on contracts. "We need to look at tightening them for compliance."
The process is somewhat automated, but Carroccio said they are implementing a module in Meditech and will be increasing that usage. "I have to give Tami Bates a pat on the shoulder. The two vendors we are in negotiation with said: 'Oh, my goodness, you are using this more than any other hospital. Wow, we want to optimize this.' So, we can work on what we have now and potentially get a workflow going."
Angelia Payton, the new risk manager, works with Banner in Denver, and has been in risk management. "She is an RN and has a wealth of knowledge she has gained in risk management for over 10 years. We are excited to welcome her here."
Miller asked if a lawsuit goes to risk management first.
"It goes to compliance and then to risk management," Carroccio said. "We want to mitigate any risk."
Garcia asked if software was available, to which Carroccio said: "Yes, Meditech has a quality module. We are doing a demo to see if it meets our needs. It's painful to be on paper right now."
Stokes said the new director of medical services, who was introduced at the beginning of the meeting, also came from Banner, and "she is extremely qualified."
He gave the report for the month of May. "Our net patient revenue was $5.5 million, with operating expenses of $5.1 million." However, with depreciation and amortization, the excess revenue over expenses stood at a negative $183,000, leaving the hospital year to date at a negative $510,000. "This compares to a negative $6.9 million this same month last year. We will have good months and some not so good. May was one of the latter."
Stokes said in the first 15 days of June, Gila Regional billed $1.7 million more than the average of the past three months. "We are getting claims out the door. We have moved the barriers between departments and have identified the multiple issues with billing documents. We issued mapped billing documents. For instance, for Presbyterian Health, they required 100 percent manual hand done intervention. Through working with HRG (Human Resources Group), we have developed a fix and we sent out the first claim last week that did not require a person to touch it. We know that some issues will be fixed as soon as we go to Meditech 6.5, but we have identified them. We are also in the process of cleaning up accounts receivable (AR). We have found accounts in AR back to 2015. In June, we are administratively adjusting them, if they are not collectable. They are worthless, so it's the right thing to do. It will be a hit as we are moving through them."
He said the hospital had a change in the business office director, as the interim was not working out. "We brought in a lady with a tremendous amount of experience, most recently in North Carolina working in the denials process. Denials are the root of where we start fixing problems. We are working it heavily. Internally, we changed the process for oncology bills. We used to hold them for 30 days before the bill dropped. We have shortened the process. Why the 30 days? The answer was that they were recurring patients, but it makes no sense to cycle bill them like you do with physical therapy. We created a different patient type. We will get the system to take over the billing by the end of next week. We are strengthening the current coding process. I get involved with querying physicians. If they are slow I contact them. We had one $100,000 bill that needed one short answer. I called the physician, got the answer and it went out that night. The year-to-date impact has been that we brought in $465,000 more."
The process is making sure that there are no barriers between departments," Stokes continued. "Through the collaboration of the business office and medical records, we had a revenue code mapping error in the system that brings in denials. We have identified the error and corrected it."
On the Meditech upgrade, Stokes said Mary Healy, finance manager from Navin-Haffty spoke to the Board of Trustee's Finance Committee. "She said Meditech is one of the most important tools for patient safety. Taffy has done a great job of matching Meditech and the patient. It's very clear when an organization is siloed that you don't get interaction among departments. Meditech doesn't work if things are siloed. Each department has its own module, but every module affects other departments. We have to understand the system thinking, which makes it a good program."
He said: 'The thing about Gila Regional that is special, is that in a lot of other places, the caregivers are resistant to change. At Gila Regional there may be a little bit of resistance, but here I have seen a willingness to work together, especially in nursing. It's refreshing to see movement among the staff."
On the key performance indicators, patient admissions dropped in May 2018 to 164 from 174 in May 2017. Patient days were 457, compared to 563 last year. Average daily census was at 16.3 compared to May 2017 at 20.1. Average length of stay was 2.8; in 2017, it was 3.2. "We are managing patient stays better."
In May 2018, ER visits stood at 1,315 compared to May 2017 at 1,472. "ER visits are trending downward. If we get the Fast Track system working well, I think we can see some recovery there."
Miller noted that some are going to urgent care instead. "Although it's not a fast track at urgent care, by any means."
Morones said the trend needs to go up, so that some are admitted to the hospital. Stokes agreed and said patients have demanded the faster service, and the hospital is meeting that demand.
Days cash on hand is the same as last year at 63. "We burned 10 days in cash on hand from last month, with some in the transition of the Pharmacy Department to Cardinal Health.
Days in accounts payable is 51 from 43 last year, but Gila Regional reduced days in AP from 56 last month. Days in gross accounts receivable is up to 69 from 42 in 2017. Full-time employees came in at 487 down from 520 last year. Overtime is fairly steady at 3.7 percent. "We still have a strong case mix."
"In oncology activity, we exceeded last July's number, so it is trending upward," Stokes said. "As of June 21, we are anticipating 144 patient admissions for June. In surgery, we expect to be about the same as last year at 317."
He said that in accounts receivable, they took a dip from the end of May into June. "Unbilled means the patient has been discharged, but not yet billed. At the end of May 2018, we had $5.247 million unbilled. It's been consistently high since June 2017. But on June 24, 2018, we worked it down to $3.142 million."
"(Controller) Alfredo (Pachecho) brought this to my attention and it didn't make sense," Stokes said. "We looked at the report and the medical records didn't agree with accounting. They were hung up in the system. We cleared a lot, got them fixed, billed and out."
For the past two weeks, they have been validating the report that Meditech generated. "With Navin-Haffty, we have worked closely to edit the report to represent what it's supposed to say. We were at $1.4 million on unbilled that shouldn't have been on unbilled. Today, we're at $702,000 on unbilled, which sounds about right. Now we have a report we can reply on. It gives you an idea how quickly we are moving through the system. We're still in testing today for validation, then we will move it to live. Mary Healy makes me stick to the testing. It's the right thing to do."
He also reported on a snapshot of denials, "which is not a pretty picture. There are multiple reasons. When HRG took over the billing accounts, there were so few notes, they couldn't determine the status of what's been done. The RA (remittance advice) code, now we know it was not mapping to the correct code. Now that we know it, we're working on it."
Garcia said: "This is transparency. We need to know these things. Now we can see how quickly we are moving to correct errors. "
Stokes said at the weekly revenue cycle meeting, they are updated on what happened the previous week. "When I asked on June 27, what was planned, there was silence. The HIM (health information management) director said they have made so many changes, they wanted to stabilize what they were working on and vet it over the next seven days to make sure it's working correctly. It's a great team."
On the Finance Dashboard in their packets, trustees saw that cash as a percent of net revenue stood at 92 percent. The numbers do not exactly match his report, he said, because they include the clinical networks.
Stokes said: "The target is 100 percent, so we still have opportunities. Some of the corrections in Meditech didn't occur until June. We will see the needle move in July. In accounts receivable for the unbilled, at the end of May we were at 10 days. Our target is a total of three days. By the end of June, we will be there. For third-party receivables, we have a target of 32 days; we're at 41. Changes to self-pay will occur in July."
To a question about the 32 days, he explained it represented the average age of the bill before it is paid.
"We also have in house accounts for those not yet discharged," Stokes said. "They have not been final billed. It's the discharged, but not final billed where we want less than one day. We are at 8.6 days. That will be around one day for June.
"For aging Medicare, meaning more than 90 days since billed, we stood at 40.5 percent of our accounts," Stokes said. "I want the board to understand this. Our target is 7 percent. We have a lot of opportunity. HRG is going back to oldest accounts that are near timing out. We've got to get the older ones out for payment before they fall off. We're looking at Medicaid with 51 percent of accounts greater than 90 days. Blue Cross, we expect 7 percent at 90 days, and we're at 20 percent. So, we have the targets. This is how we will gauge as we progress down this road. Denials, you'll start seeing populated next month. It goes back to communications. HRG and Gila Regional put information into logs. Self-pay, we just transitioned last Friday."
He explained the dashboard on trustee's computers continues to go into details.
Year-to-date 2018, the hospital collected 19 percent of Medicare charges, as well as 19 percent from Medicaid. "Medicaid is the lower payer, so that's not far off, but Medicare should come in around 28 percent to 31 percent. We have a 10 percent opportunity there. As we get the system working better, we want to begin to curve the bend up in July. Other hospitals have a higher charge system. I think the majority of variance is because of issues within the system. Getting the claim out correctly is critical. I want to know the line item denial, so if we have misused a code for a code denial error, we can fix it. We are getting the basics under control. Now we need to step up another level. We receive 48.1 percent of our revenue from Medicare, so we need to increase that 10 percent. It all ties together."
Stokes said he has given the good news and the bad news. "I want you to understand that we have a good team of smart people working on these issues. And I'm very happy to see staff willing to bring issues to us."
"I'm going to talk about the budget first, before I turn it over to the fellow who created it," he continued. "I've talked to the Board of Trustees and Taffy about the budget. What is driving me every day and night is how to manage net revenue. Of course, we've spent a huge chunk of time responding to the County Commission. I asked Alfredo to build the budget. He has the right approach. The only thing we can project in this budget is our net revenue improvements. Everything else, and I emphasize everything else in our strategic plan, has been put on hold."
Pacheco said he has been in places where the administration puts out the numbers and force feeds it to the directors. It doesn't seem to work well. "My philosophy is to look at the responsibility of the directors to help build the budget. I met with all the directors to get them to sign off on their budgets. Next year, I will explain their variances and put together next year's budget. I held most of them to provide me with numbers of this year's budget. We are projecting a 5 percent gross revenue increase and small increases in volumes in some departments. Revenue reductions are a percentage of gross revenue. We had a $4.5 million decrease in deductions, because of efficiency. There have been changes in the safety net care pool. The overall budget is not too aggressive, not too conservative, with a margin of less than 1 percent. We can get there, but we want to be not aggressive. I made adjustments to the budget with the salary increases for bedside nurses and the related benefits. They have been incorporated into the budget. It is very much in line with where we are currently at."
Stokes said the budget was done for right now. "We want to update it in January, based on activity. This all assumes that the hospital will stay as we are. We will be implementing budget projections in coming months. We will be able to generate numbers, so Taffy can make the right decision when she needs to. The labor productivity system equals to activity."
Pacheco said they reached out to the state to make sure they would abide with requirements. "We submitted the preliminary budget on June 1. The next deadline is July 31 for the final budget. For several state budget forms, we have to separate out items. We still have to provide the year-end balance sheet and the fourth quarter document."
Stokes asked that the final budget by approved at this meeting, so it showed in the minutes, because that, too, is required.
"I'm not sure this hospital has abided by state requirements, especially the separate forms, in the past," Pacheco said. "It will be ideal to have an approved budget."
Morones noted that the budget they were approving is actually the executive summary of the budget. "All departments aggregate to this budget. When we presented out strategic plan to the public, we showed we can be up by $10 million this year, but we cannot start on the plan until we have certainty. This budget shows a modest $1 million profit. This is a very realistic budget."
The budget was approved.
The chief of staff report was next, but Dr. Gregory Koury had texted Garcia that he was very busy in the ER and would come to the meeting when he could.
Garcia said the executive committee discussed the agenda.
Miller stepped in to report for Dr. Tsering Sherpa for the Quality Improvement Committee, where the members discussed the private rooms. "The patient experience steering committee will made decisions on improving the rooms."
Garcia reported for the Finance Committee, which had no contracts to be approved at this time. "We are handcuffed."
Schram gave the Plant and Facility Committee report. "We discussed a couple of items. You've already heard about the changes to the Behavioral Health Unit. We also talked about the concrete repairs needed outside the Emergency Room. A lot of reports on equipment needs were resolved."
Miller said they also had a lot of discussion in information technology. "It sounds like they are working their tails off."
Trujillo said Human Resources did not hold a May meeting, because there was nothing striking to discuss. "I do note the negative numbers for contract labor, but I know a lot of that is because of Meditech."
Pacheco said the previous Meditech problems were built into the contract. The salaries were moved out after closing the previous contract to reflect previous expenses that were moved to assets.
Stokes said they made sure it was OK for the audit.
Miller noted that a number of applicants jumped up. "We hired 41 people."
The nominating committee nominated Morones for chairman, Dr. Victor Nwachuku for vice chairman and Schram for secretary-treasurer. All positions were approved for the board executive committee.
"It's always good to have one of the doctors on the executive team," Morones said.
The board members took a 15-minute break before going into executive session.