SOUTH PENINSULA HOSPITAL, INC. REGULAR BOARD MEETING SPH Conference Rooms January 28, 2015 Call to Order The BOD went into Executive Session to discuss personnel and financial matters prior to the start of the regular meeting. *****Into Executive Session 5:02 p.m. ***** *****Out of Executive Session 6:52 p.m.***** ***** Regular Session 7:00 p.m.*****. President Tom Clark called the regular meeting to order at 7:00 p.m. Present: Matt North Vickey Hodnik Susan Drathman Tom Clark Caroline Venuti Julie Woodworth Todd Boling Matt Hambrick Bernadette Wilson Barbara Howard Also Present: Robert Letson, CEO Lori Meyer, CFO Dr. Giulia Tortora, Chief of Staff Leslie Haynes, QI/UR/RM Director Shara Sutherlin, Director of Patient Care Services Jacqueline Lenew, SAB Representative Laura Hansen, Executive Assistant Kelly Cooper, KPB Assembly Representative Barbara Huff Tuckness, Teamsters Steve Hughes Peggy Frazier Cris Beaudoin Kim Greer Katie Watson Becky Lundqvist Jean Aspen Heather Rothenberger Mikel Kuhn Lydette Kieffer Maria Victoria Soto South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 1 of
Page 2 of Jane Nollar Lina LePage Dana Whittaker Dottie Zopp Eva Stovall Priscilla Estill Marilyn Shroyer Anna Williams Ginny Werthwein Robbie Coffey Sherry Catterfeld Kathi Collett Jan Hanenberger, Homer Secretarial Services A quorum was present. Announcements, Welcome Guests & Public President Clark welcomed everyone. He mentioned the Rules for Participating in a Public Meeting were to be followed and asked that everyone conduct themselves professionally and respectfully. Approval of Agenda Howard/Woodworth moved/seconded: To approve the agenda. Ms. Howard requested the following: Move Item C under the consent calendar, Consideration to Approve Wound Care Proposal, to the appropriate spot on the agenda under New Business. Move Item D under the consent calendar, Consideration to Approve Infusion Pumps, to also be under New Business. She then asked for a second and consensus on the motion. Ms. Woodworth seconded the motion. There were no objections and the motion passed. Comments of Audience Cris Beaudoin thanked the board for their support of the Healthy Workplace Council, and mentioned the council had not yet received the letter of support from Administration. Steve Hughes read a statement he had written regarding some concerns and the working environment at SPH. Peggy Frazier read a statement regarding the current working environment and patient safety at SPH. Kim Greer read a statement regarding the workplace environment and patient safety at the hospital. She said as a group they would like to recommend a small cross- South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 2 of
Page 3 of section of union and non-union employees meet with the President and Vice President of the board. Maria Soto said there are some serious issues at SPH which need to be addressed. Approval of Consent Calendar Woodworth/Hambrick moved/seconded: To approve the consent calendar as amended. Ms. Wilson read the consent calendar items into the minutes: A. Consideration to Approve the Minutes of the December 17, 2014 Board of Directors Meeting B. Consideration to Approve Changes to SM-07, Board Orientation C. Consideration to Approve Form 990 D. Consideration to Approve Market Rent Analysis E. Acceptance of Annual Report to Contract Administrator F. Acceptance of Annual Corporate Compliance Report G. Acceptance of Education Committee Annual Report H. Acceptance of Governance Committee Annual Report There were no objections. Motion passed. Presentations: No items on the agenda. Reports: A. Chief of Staff Dr. Giulia Tortora said she felt that after several years of ups and downs, she is very concerned about the current morale of employees at the hospital. B. Service Area Board Representative Jacqueline Lenew mentioned the following: The SAB is looking forward to the BODs budget requests. The next SAB meetings are February th, and March th. C. Chief Executive Officer Robert Letson s report was included in the packet. He mentioned the following highlights: Donna Rollins, Psychiatric Nurse Practitioner, started her practice this past month and will be working closely with Homer Medical Clinic. The quarterly KPB Assembly presentation went well. The recent CEO Breakfast went well. For the next two weeks Dr. Teresa Johnson will be covering at Homer Medical for an interview and locums tenens. South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 3 of
Page 4 of Dr. Downey has settled into the Ninilchik Clinic and is also helping in LTC and Employee Health and Infection Prevention. He has also agreed to help the Medical Staff comply with new licensing and coding process. Dr. Tanner has a new partner, Dr. Medland, who will be coming one day a month. Dr. Medland has expertise in thyroid and adrenal disease. Robert Hixon, new physical therapist, has started and there is no longer a waiting list. Bonita Banks is now the Wellness Coordinator for Community Education. On March 19 th through March 22 nd SPH will be participating in an emergency exercise with the city of Homer, KPB, Emergency Management, Alaska State DHSS, Air Alaska National Guard, and CPH. There were no questions of comments. D. LTC Administrator Mr. Letson s report was included in the packet. He mentioned: Ten rooms have had flooring replaced, as well as deep cleaned and painted. They are very close to implementing hour shifts, which has been favorably received by the employees. The LTC recently held its Annual Skills Fair. They are continuing work on fall prevention. Heather McHenry, one of the LTC nurses, will be the new instructor for CNAs at the college. Resident census for LTC is full with 28 residents. There were no questions or comments. E. Chief Financial Officer Ms. Meyer s report was provided in the meeting packets. She mentioned the following: At the request of the SAB members the financial information format has been enlarged for easier reading. Revenue was over budget for the month of December. Expenses were also over budget. There was a loss from operations of $405,000 compared to $600,000 budgeted. EBITDA was a negative $152,000; year-to-date it is positive $2,190,000. A/R days decreased two days from last month. Questions and answers followed. South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 4 of
Page 5 of F. Patient Care Services Ms. Sutherlin s written report was included in the packets. She mentioned the following highlights: Imaging has a fulltime CT Technologist position available. MRI was upgraded in December and will decrease anxiety in patients who are claustrophobic. Teach back has been added to the list of customer service rules in Imaging. The BioFire FilmArray has been validated and gastrointestinal, respiratory and positive blood culture panels are being offered in the lab. The lab is bringing in HIV fourth generation test current best practice. In Acute Care, the OB Department is planning for 20 babies in March. AC is starting to interview candidates for some available staff positions. New Pharmacist, Chelsea Dubbe, is now in her last month of training in the Pharmacy. They will be looking for a Pharmacy Technician this summer. There is no waiting list in rehabilitation. Home-based Health Services has a fulltime Home Health RN position posted. Surgery has been very busy and has done 1,658 surgeries. Kenny Rogers has been hired as the new Clinical Manger of the Emergency Department. Questions and answers followed. G. Quality Improvement Ms. Haynes written report was included in the packet. She mentioned the following highlights: 2014 Hospital Wide Goals: 1. Reduce Hospital Readmissions by 40%. Goal was 15.8%. Goal was not met and came in at 26% and lower than last year. 2. Reduce Hospital Inpatient Falls by 50%. Goal was 3.85%. Goal was not met and came in at 5.5% and lower than last year. 3. Reduce LTC Falls by 50%. Goal was 2.1%. Goal was not met and came in at 6.1%. 4. Reduce Hospital Acquired Infections by 20%. Goal was 2%. Goal was met and came in a 1.8%. 5. Core Measure Metrics will be >90% overall. Goal was met with overall rate of 96%. 6. HCAHPS Scores will be>80% overall. Data not yet available. Dr. Downey is the new Infection Prevention Medical Director. Dr. Reynolds and Sherry Catterfeld, RN, were featured in the December edition of Alaska Nursing Today magazine. Ebola preparedness continues. New Infection Prevention education was created for LTC. South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 5 of
Page 6 of Infection Prevention will be involved in a Nurse Preceptorship, UAA School of Nursing, beginning 1/21/15. Approximately 62% of staff have received flu vaccinations. With outstanding hard work, 68 peer reviews were completed in 2014. Staff has found a new way to capture revenue for the hospital with a new coding called Administrative Wait Beds. Current patients, who will require nursing home level care upon discharge, and are authorized by Senior and Disabilities Services, can be provided with care in an acute institution while waiting for services to become available. This is an Alaska program and the amount of the daily revenue is $485 per bed. Questions and answers followed. H. Marketing Report Written report was included in the packet. CEO Letson mentioned: February is Heart Awareness Month. Promotions for Dr. Sarah Spencer s clinic for Addiction Medicine, Dr. Jeffrey Simerville, Urology, and Dr. Jeff Medland, Endocrinology and Thyroid Health, will start soon. March will feature Colon Health promotions. There were no questions. I. Board President President Clark s report will be during the SAB report. J. Board Committees: Finance Mr. Hambrick mentioned the Finance Committee s Annual Report had been provided as a laydown this evening. There were no questions. Governance No report. Education Ms. Wilson said the committee met. They reviewed specifics for the upcoming annual board work session. The theme is continuing with Charting the Course, Culture of Patient Centered Care. Dates have been narrowed to April 17 th and 18 th or April 24 th and 25 th, with the speaker preferring April 14 th and 25 th. Ms. Wilson then reviewed some specifics requested by the speaker and suggestions by the committee. Laura Hansen was asked to attend and document the session. South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 6 of
Page 7 of Pension Plan Mr. North mentioned the committee is scheduled to meet Monday. BOD representative to SAB meeting President Clark attended the last SAB meeting. KPB mayor and staff were also present. Mr. Clark reported the mayor announced plans to pursue borough wide health powers in order to control healthcare costs. This would mean the hospitals would be joined and run by one board, similar to the school board. He also mentioned Brent Johnson, KPB Assembly Representative from Anchor Point north to Clam Gulch, is proposing an ordinance to change the size of the service area, which would decrease revenue to our service area. Comments followed. Unfinished Business No items. New Business A. Election of Officers Ms. Drathman mentioned the members would be voting by secret ballot. Nominations would start with the President. Current President Clark opened nominations for President. Woodworth/North moved/seconded to nominate Tom Clark. Ms. Howard moved to close nominations. Vice President: Woodworth/Hodnik moved/seconded to nominate Matt Hambrick. Wilson/Howard moved/seconded to nominate Julie Woodworth. Secretary. Woodworth/North moved/seconded to nominate Bernadette Wilson. Treasurer: Hambrick/Howard moved/seconded to nominate Julie Woodworth. Officers elected were: President Tom Clark Vice President Matt Hambrick Secretary Bernadette Wilson Treasurer Julie Woodworth South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 7 of
Page 8 of B. Consideration to Approve Notice of Change of Officials & Reorganization Woodworth/North moved/seconded: To approve. Motion passed. C. Consideration to Approve Board Bylaws Woodworth/Howard moved/seconded: To approve. Discussion followed. Since there currently are no recommended Bylaw changes it was decided this was for information only. Ms. Woodworth and Ms. Howard retracted their motion. D. Consideration to Board Roster/Committee Appointments Comments and questions took place. Hambrick/Howard moved/seconded: To approve revised Board Roster with updated information. Motion passed. E. Review BOD Bylaws Proposed Changes Woodworth/Hambrick moved/seconded: To table this item until the February meeting. Motion passed. F. Annual Forms: Conflict of Interest, Board Information for CMS, Confidentiality Agreement Laura Hansen asked that members complete the forms and return them to her. G. Consideration to Approve Wound Care Proposal CEO Letson provided information on this item which would be a new out-patient service in the Specialty Clinic Annex and recommended approval. The cost would be just over $9,000, the projected revenue for the first year is $75,000, and the funding would come from operations. Howard/Boling moved/seconded: To approve the Wound Care Nurse Certification proposal. Discussion followed. Ms. Wilson requested amending the motion to include the costs and funding source. The maker of the motion and the second agreed to the amendment. Motion passed. H. Consideration to Approve Infusion Pumps Howard/Woodworth moved/seconded: To approve the Carefusion Pumps. CEO Letson provided information on the need for the Baxter/Sigma pumps. A 60 month capital lease for acquisition of all pumps is recommended through CalFirst. The cost would be $87,600 per year. If approved this will be forwarded to the SAB and KPB Assembly for approval. South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 8 of
Page 9 of Discussion: Ms. Wilson requested a friendly amendment for the motion to include consideration to approve a capital lease, through CalFirst, at a cost of $87,600 per year, times five years. Maker of the motion and the second agreed to the friendly amendment. The vote: Yes: Clark, Boling, Hodnik, Howard, North, Venuti, Drathman, Hambrick, Woodworth, Wilson No: 0 Absent: 0 Motion passed. A. Rural Healthcare Leadership Conference Phoenix, February 8 11 Some board members and staff plan to attend. B. Service Area Board BOD Attendee February et al. Members are needed for February, October, November, and December. Mr. Hambrick will attend the meeting on February th, and Caroline Venuti on October 8 th. The member attending should be prepared to provide a report on BOD activities to the SAB. C. Plans for Doctors Dinner Dates in March Harborview Room Available on March 3 rd, 5 th, or 10 th March 3 rd was chosen for the dinner. Suggested topics should be emailed to Ms. Drathman. Comments from the Audience Kim Greer had the following questions: 1. Would the borough wide healthcare control issue be a public voting issue? Kelly Cooper, KPB Assembly Representative, said she would like to comment on this question during her comment time. 2. Will the new wound care service be provided by a newly hired person? Mr. Letson said it would be an existing nurse at SPH who would be taking the certification training. 3. How are complaints counted and are positive comments also counted? Ms. Haynes said each person is counted but they may have three complaints. Positive comments usually go to the unit the patient is in and Administration but rarely come to QI. South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 9 of
Page 10 of Barbara Huff Tuckness, Teamster Representative for SPH, wanted to go on record thanking each staff member for speaking to the board this evening about their concerns. For the record she said the Teamsters do not air certain things in public. She then mentioned a letter she had sent to Mr. Letson, with copies to the board members, and her concern for the problems and issues at the hospital. Kelly Cooper, KPB Assembly Representative, commented on Brent Johnson s proposed ordinance regarding changing the service area boundaries. She said the mayor s proposal regarding borough wide healthcare powers is a very long process and it is not known yet if it would come to the public for a vote. There currently is an ordinance in front of the assembly to establish a taskforce to study healthcare issues. With enough notice assembly meetings can receive public testimony from the local annex office. There will be a public hearing on the marijuana issue on the 24 th and the annex office will be open for testimony. Sue Shover, LTC Director, mentioned a Nursing Home Compare form had been provided as a laydown for the members. The form showed SPH LTC received the Five Star Quality Rating. Maria Soto applauded the LTC staff for their hard work. She also wanted to acknowledge and personally thank the ER staff for their handling of the major event on Christmas. Comments from the Chief of Staff No comment. Comments from the Chief Financial Officer No comment. Comments from the Chief Executive Officer Robert Letson said he looks forward to working with the board, senior managers, employees, and union representatives. Comments from Homer Secretarial Services Jan Hanenberger welcomed Ms. Howard and Ms. Venuti and thanked everyone. Comments from Service Area Board Representative Jacqueline Lenew thanked the board members. Comments from Board Members/Staff Dr. Vickey Hodnik thanked Ms. Venuti and Ms. Howard for filling the vacancies and would now like to move forward. Bernadette Wilson thanked the employees for coming and addressing the board, and congratulated LTC staff. Matt North thanked everyone for their time. South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 10 of
Page 11 of Julie Woodworth thanked everyone. She mentioned there was good news under Hospital Compare and shared some of the SPH information. She echoed Ms. Soto s comment regarding the Christmas accident, and thanked the individuals who spoke this evening. Caroline Venuti thanked everyone for sharing their thoughts, and felt there are solutions and issues could be worked out. Susan Drathman welcomed Ms. Howard and Ms. Venuti, and thanked everyone for coming and all their work. Tom Clark thanked everyone for coming, and appreciated how hard it is to bring tough subjects to the board. The board will be working through Mr. Letson on all issues and facilitating towards solutions. Announcements as a result of the Executive Session After review of the applicants files in Executive Session, Ms. Wilson moved to approve the following positions in the Medical Staff as requested and recommended by the Medical Executive Committee: Appointment of: Paul Davis, M.D., Locum Tenens Teresa Johnson, M.D., Locum Tenens Richard Kilby, M.D. Jeffrey Simerville, M.D. Reappointment of Allied Staff: Martha Cotton, M.D. Linda Ireland, M.D. Ms. Woodworth seconded the motion to approve. Motion passed. Executive Session The board then recessed the regular meeting and reconvened Executive Session. *****Into Executive Session 8:35 p.m. ***** *****Out of Executive Session 9:40 p.m.***** Announcements as a result of the Executive Session There were no actions taken. South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page 11 of
Page of Adjournment: Hambrick/North moved/seconded: To adjourn. Meeting adjourned at 9:42 pm. Respectfully submitted, Janet E. Hanenberger Homer Secretarial Services Minutes Approved: Accepted: Tom Clark, President Bernadette Wilson, Secretary South Peninsula Hospital, Inc., Regular Board Meeting, January 28, 2015 Page of