Board Meeting Highlights and Minutes October 27, 2011

Highlights from the Board of Trustees Meeting 10-27-11:

Special Announcements:

The Board presented Pam with her own special piece of the hospital – a portion of the stone that was off the original hospital and is going to be used again in the renovation. This memento was given to Pam to commemorate her work in building both the original and new hospital expansions.

Lynn presented the St. John’s Medical Center Nurse of the Year Award to Alan Sousa. Alan was also nominated and was a finalist for the Wyoming Hospital Association’s Nurse of the Year Award. Alan was nominated for his work in implementing all the new IT initiatives and he is a great team member and a pleasure to work with. Alan was very appreciative of this award and said he was very thankful to be a part of such a wonderful team.

Education:

Ann King White from BKD gave a presentation to the board regarding Medicare Rural Payment Opportunities. She explained the evolution of Medicare as a purchaser, what effect Health Care Reform has on Medicare payments, what it means to be a sole community hospital, the criteria for being a Rural Health Clinic, and what is the future of these rural programs. She also discussed the 2012 proposal for the Medicare physician fee schedule. The medical community continues to urge congressional leaders to permanently fix the broken Medicare Physician payment system and replace it with a stable and predictable method of payment.

Laura Lapidus, Risk Control Consulting Director for CNA, gave a presentation on Director and Officer Liability Insurance. She explained what some of the risks are for members serving on non-profit boards. She reviewed general board duties, board member obligations and what important governance documents are needed. Bylaws must be kept up to date, records and meeting minutes must be properly documented and members must comply with all applicable laws and regulations. She gave some examples of potential claims asserted against not-for-profits and how to control risk.

Minutes:

The Board approved the minutes from meetings held on September 22, 2011, September 26, 2011, September 29, 2011, October 1, 2011 and October 3, 2011. These minutes will be available at http://www.tetonhospital.org/about/board/meetings.

Old Business: None

New Business:

Ann King White from BKD presented the Audit Report for Fiscal Year 2011. She announced that St. John’s received a clean unqualified opinion with no material weaknesses or significant deficiencies and only one audit adjustment recorded which was a debt retirement posting. The total current assets are $44,578,948, days cash on hand was 201, and net patient A/R was $8,954,263 with net days in A/R 50.9. The total liabilities and net assets came in at $107,122,570. Under operating results the increase in Net Assets was $8,340,355. Property tax revenues covered about 53% of the charity care and bad debt expense. Total operating expenses came in at $67,820,564 and cash/cash equivalents were $29,569,390. The Board approved the audit report as presented. Congratulations to the entire accounting team.

Mike Tennican announced that Mike Brennan left his partnership at Holland & Hart to go into a specialized practice in environmental and resource issues and will not be continuing on as hospital general counsel. The board will be in the process of selecting someone to move into that role. Until then Nick Healey, our healthcare legal counsel, will assist with this role.

Kathy Byron gave the Quarterly Quality Report. Third quarter data continues to show positive trends in the majority of core measures. The Surgical Care Improvement Project core measure went up from 92% to 99%. Substantial progress was seen in the VTE category. Community Acquired Pneumonia went down but four other elements of this measure achieved the 100% target. Safety indicators include medication error, adverse drug event, and fall rates per 1000 patient days for both acute care areas and Living Center. Hand Hygiene remains the most important method to reduce transmission of pathogens in healthcare settings and compliance is up to 91%. In the Living Center the fall rate did increase but the Fall Team analyzed the falls, made changes in the resident’s environment and falls have now decreased.

Janet Olson gave a review of the Infection Prevention Program and a summary of the infections that occurred. Our infection rates continue to be low. The action plan is to continue education with all staff related to post-operative care and infection prevention. We will also continue multidisciplinary collaboration among all caregivers, specifically nursing, cardiopulmonary, and physical therapy.

JCC Report:

Barbara Herz just wanted to note that it is very important for the members of the medical staff to participate in the next strategic planning meeting which will be November 10th.

Credentialing and Policies:

Dr. Payne presented the proposed Clinical Privileges policy which addresses practitioners who do not treat patients here but allows for a privilege category so practitioners can refer their patients to the hospital but they would be cared for by other physicians. Physicians need a minimum of 20 patient encounters per year to maintain clinical privileges. The Board approved this new policy.

Dr. Payne then presented the credentialing recommendations as listed in the JCC report as follows:

Change in Staff Status
The JCC recommends approval of the following change in staff status: Michael Gellis M.D., Plastic Surgery, Provisional to Active 11/1/11.

Requests for Change in Privileges
The JCC recommends approval of Dr. Marian Butcher’s request for a change in privileges from Psychology privileges to Refer & Follow.

Reappointments
The JCC recommends approval of the following reappointments:
• Kerry Carr ANP, AHP, Nurse Practitioner, Dr. John Ward sponsor, 11/1/11 – 10/31/13.
• Elizabeth Gilmour LPC, AHP, Professional Counselor, Dr. Steven Nelson sponsor, 11/1/11 – 10/31/13.
• Ellen Meyers MD, Active, Internal Medicine and Critical Care, Hospitalist, 11/1/11 – 10/31/13.
• Alton Parker MD, Provisional to Active, General Surgery and Critical Care, 11/1/11 – 10/31/13.

New Appointments
The JCC recommends approval of the following new appointments:
• Preceptee – Matt Hand, MS-4, WWAMI, Orthopaedics, 1/16/12 – 2/12/12, Dr. Khoury sponsor
• Preceptee – Maria Corcorran MS-3, WWAMI, Pediatrics, 11/7 – 12/18/11, Dr. Riddell sponsor
• Preceptee – Matthew Swanson, MS-4, WWAMI, Orthopaedics, 10/24 – 11/18/11, Dr. Khoury sponsor
• Michael Ross Pieper DO, Family Practice & OB, requesting Surgical First Assist privileges for C-sections, Drs. Lofaro and Roberts sponsors 11/1/11 – 10/31/12
• Jason Su DO, Consulting, Pediatric Cardiology, 11/1/11 – 10/31/13

The Board approved all of the recommended items.

Dr. Payne called a special medical staff meeting last week to discuss and approve medical staff bylaws changes which address separation of clinical privileges for medical staff membership. A few more issues need to be considered before presenting this to the Board for action. There will be a special meeting on November 18th at 7:00 am for Board members and members of the medical staff to discuss current concerns and issues.

Finance Committee:

Joe Albright through the Finance Committee asked the Board to approve the bond resolution for the 2011 C bonds that we have as a contingency and can use to bridge the funds from SPET. The current interest rate is 1.75% and we can repay the loan at any time without penalty. We are also not obligated to go out and use this line. The Board approved the Bond Resolution Agreement. Joe also accepted to be the temporary Secretary of the Board as that position is now vacant, so he could sign the necessary documentation for this Agreement.

John Kren noted that he will be giving some of his current CFO duties to Alisa Lane to oversee while he is operating in his dual role as CFO and Interim CEO. All of the members of the accounting team will see some shifting of responsibilities to assist during the transition.

Facilities Committee:

Jim Johnston was not able to attend the meeting so Gary Trauner gave the following update. He noted that the project is moving forward. The digging of the basement should be done by next week. We are working with the state on items from their review and hope to be pouring concrete within the next two weeks once the state gives preliminary approval.

Visit us at http://www.tetonhospital.org/expansion-home to see updated information and view our progress in real-time on our new WebCam.

MRI Committee:

Mr. Tennican stated that no formal meetings have been held this month but it is his understanding that they may receive a proposal to delay the dissolution of Teton MRI.

Personnel Committee:

The main objective now is to consider candidates for the CEO position. The position has been posted and there are several applications to be reviewed by the CEO search committee.

The other task is the consideration of a board member replacement. There isn’t enough time to be able to review potential candidates and go through the interview process by the November meeting but we hope to have this done by December. Currently there are 3 candidates. The Board will continue to take applications until Tuesday, November 8.

Foundation:

Liz Finegan opened her report by noting that BKD also did the Foundation’s audit and they did very well. She thanked Rick Stuck and the accounting team for a great job. Several events including the Golf tournament, stroke is no joke, the pediatric audiology conference and Old Bill’s. The Fun Run received a total amount of gifts for the hospital of $154,000. The donors are interested in giving to chemo, cognitive health, pediatric audiology, nurse education, CHI Center, diabetes, hospice, child care, pediatrics, living center and Mary mead Life Line. They got a check from the auxiliary of $75,000 from Spring Fling and the gold tournament. The Brinson Foundation has again committed to another $40,000 for nurse education and obstetrics. They are submitting a grant for defibrillators for the POB. They are hoping to get a total of 5. The cardiopulmonary group will train those who want to learn how to use these. They are also submitting a grant for The Cognitive Health Institute for caregiver training as well as to expand the dementia library in the CHI Center. Liz attended the International Association of Healthcare Philanthropy and the giving front looks tough this year. Please take a role in supporting St. John’s in all of the various areas of interest.

Report from the County Commissioner:

Paul Vogelheim had a few items to discuss. The county continues to do some needs assessments and has 3 that are coming up on daycare, public health, counseling and drug court and dependency issues. They have talked about the wellness program and are excited about how the hospital is moving forward with this. The county is looking to implement something about a year down the road. They would like come back and talk to the Board soon regarding EMS and ambulance support. Last they continue to have more meetings on the comp plan now through Tuesday.

Reports from Administration:

Mike Tennican noted that members of the Administration had previously given written reports to the Board and asked if there were any updates.

Lynn Campbell gave an update on the Joint Commission Survey. There was a great article in the paper this week on how well all areas of St. John’s did. There were four surveyors here for three days and they looked at everything and everyone and had just a very short list of items that need to be addressed. This was the best survey Lynn had been involved with and thanked Kathy Byron and the members of the survey ready team for the exceptional job they did in getting the facility and everyone survey ready. She noted that the survey could not have been this successful without the efforts of the entire hospital staff and medical staff.

Gary Trauner added that Jim Johnston said that the life safety surveyor had never seen a facility as prepared as highly as ours. Jim even got a thank you email from the surveyor which he has never seen in his 18 years. Jim also asked Gary to acknowledge the Environmental Services Department for working so hard to make sure this is the cleanest hospital and working with patients to make sure all their needs are being met. The surveyor said he had never been in such a clean hospital.

John Payne noted that in speaking with the surveyors they were surprised at the lack of nervousness on the part of the staff as the survey ready team and nursing directors had everyone so prepared through the mock surveys, etc. that when the real survey hit it was “just another day.”

Karen Connelly had to leave so Sherry Wieters announced that there were a record number of visitors to the website on October 17th of 335 and a record week of 1,650 visitors which is up from the 1,024 visits we had during this same week last year. We have QR codes on all of our ads now which allow us to track how many people are getting information from our ads. We also had great success with our eblasts which resulted in 400 people clicking all the way through to see what events were going on at the hospital.

Tara Hagan gave her 1st Quarter FY 2011-2012 HR report. The turnover rate is down from last year and safety indicators show injuries are down. The management group is really happy with the new software for performance management and we are almost at 96% for completing the annual evaluation reviews.

Public Comment: None

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, November 17, 2011 with public session starting at 4:00 pm.

Thank you –

Sherry Wieters
Executive Assistant
(307) 739-7501

AttachmentSize
BOT report 10-27-11.doc52 KB
BOT pub mtg 10-27-11 + MLT.pdf53.32 KB