Board Meeting Highlights and Minutes June 23, 2011

Highlights from the Board of Trustees Meeting 6-23-11

Special Announcements:

Pat Weber announced that this month the Living Center was presented with the Governor’s Innovation in the Workplace Award. The Living Center was unanimously selected by the Wyoming Workforce Development Council for the culture they created - called the Eden Alternative. The Eden philosophy focuses on building relationships among residents, families, staff, volunteers and other community members. Congratulations Living Center! For more information visit


Kathy Byron presented an update on SJMC Joint Commission readiness. Kathy reviewed the efforts put in place last December in the development of a Survey Oversight Team, the tiered process for TJC readiness developed in January, and the ongoing educational efforts throughout the organization. One assessment method to assure compliance with TJC standards is the use of a tracer. Tracers are currently ongoing in all departments. Joint Commission arrival will be on or before September 22, 2011.


The minutes from public meetings held on 4/28/11, 5/2/11, and 5/26/11 were approved. They will be available on the public website next week.

Quality Report:

Kathy Byron also presented the Quality report for Q1, Q2 2011. Core Measure, Safety Indicators, Patient Experience Scores, and Hospital-acquired Infection data were addressed. As the majority of our data are trending upward, we are able to celebrate the successes achieved with new 2011 internal quality initiatives in place. Providing the highest quality of care in the safest environment continues to be our priority.

Infection Prevention Update:

Janet Olson presented the Infection Control and Prevention report. The Infection Control Program incorporates evidence-based practices from leading authorities such as the Center for Disease Control and Prevention. We comply with regulations from state and local health departments, the Occupational Safety and Health Administration, and the Center for Medicare and Medicaid Services, as well as The Joint Commission. The action plan includes the adoption of hand hygiene as an organizational performance improvement measure that has been put in place for 2011. Hand hygiene is the most effective way to prevent hospital acquired infections. Our current compliance rate is 86% with a goal of 100% in 2011.

Joint Conference Committee:

Peter Moyer gave the report from the JCC meeting this week. He said they discussed the progress of updating the medical staff bylaws and that everyone is ready to begin working with Dr. Sokolov in updating our strategic plan.

Credentialing and Policies:

Dr. Payne presented the credentialing recommendations, new privilege request, reappointments, new appointments, and revisions to 3 medical staff policies (R16-Health screening for Practitioners, R37- ICU Privileges, Admissions, Rounds, and R40-Physician/Practioner Practice Evaluation) that were approved in the MEC and JCC meetings. The Board approved all of the recommended items.

In addition, Dr. Payne gave a review of R48-Clinical Privileges. He stated that this policy clarifies the separation between Medical Staff membership and clinical privileges. This new policy will establish a minimum activity level of 20 patient encounters per year but will have exceptions for specialties such as oral surgery, ophthalmology or dermatology. The medical staff will need to have language added in their Bylaws that allows these practitioners to continue to be active on our medical staff.

Finance Committee report:

Joe Albright stated that the Finance Committee has been working on preparing two bond package resolutions that will move us forward in refinancing some of our old debt and secure a portion of funds necessary for the construction project. The Board approved the series 2011 A bond resolution which will refund the existing 1998 bond debt and save us approximately $200,000 per year in interest. The Board also approved the series 2011 B bond resolution for improvement project and refunding of 2002 bonds.

Next item for discussion was the FY 2012 budget. Joe informed the Board that the committee determined a price increase needs to be approved to maintain the hospital’s financial stability. It was proposed and approved that an average 3% price increase be implemented effective July 1, 2011. This increase will be averaged out across all of our service lines so some procedures will remain at the same level and others that are more generally covered by insurance will see the price increase. The national increase in hospitals and health care services is currently 5.4% so we are please we can stay below this point.

Facilities Committee Report:

Jim Johnston gave his update of the improvements we are making in the life safety measures and environment of care area. This is an area where many health care facilities have violations when going through The Joint Commission Survey. Jim thanked the Board and Administration for their support in passing our safety management plans and approving financial support so we can make sure issues are taken care of to meet these standards.

Mr. Johnston also displayed the latest schematic design plan and stated that we are starting to layout the room design now. The architects and engineers will be here July 5th, 6th, 7th for design development meetings. The exterior finished are also being reviewed and architects hope to have some drawings back to us by the next board meeting. We also have a committee that is working on the interior design for these new areas. Ground breaking is scheduled for August 9th.

MRI Committee:

Mike Tennican said this committee has been meeting for the purpose of trying to dissolve the joint venture relationship between the hospital and Teton MRI. Zach Hall and the committee have also been reviewing equipment options should we decide to purchase a new machine.

Personnel Committee:

Mike Tennican noted that the committee has been focusing on reviewing physician and physician group contracts. They are in the process of finalizing contracts with the anesthesia and emergency departments and are still working through negotiations regarding the potential purchase of 4 Peaks Clinic.

Strategy committee:

The Steering Committee which consists of Mike Tennican, Pam Maples, and Dr. John Payne has had several conversations with Dr. Sokolov of SSB Solutions and think they have a final proposal to begin phase one of the development of a strategic plan. Subsequent phases will focus on more detail such as the development of a medical staff development plan. The board approved phase one of the contract and authorized administration to finalize the contract.

These are the highlights. Final approved minutes of the board meetings and monthly financial reports are available on the public website. Please mark your calendars for the next regular monthly meeting of the Board of Trustees which will be Thursday, July 28, 2011 with public session starting at 4:00 pm. The 2011-2012 Budget will be presented for approval at this meeting.

Thank you –

Sherry Wieters
Executive Assistant
(307) 739-7501

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