BOARD OF DIRECTORS Agenda February 17, 2015 Administration Boardroom

Transcription

1 BOARD OF DIRECTORS Agenda February 17, 2015 Administration Boardroom Mission Statement Bartlett Regional Hospital provides its community with quality, patient-centered care in a sustainable manner. I. ROLL CALL II. III. PUBLIC PARTICIPATION SPECIAL ORDER OF BUSINESS IV. APPROVAL OF MINUTES from January 27, 2014 (Pg. 2) V. OLD BUSINESS A. Housing First (discussion) B. CEO incentives/annual performance evaluation (discussion) (Pg. 9) C. CERNER update Jane Sebens VI. VII. NEW BUSINESS COMMITTEE REPORTS: A. STANDING COMMITTEE REPORTS 1. Executive Committee Bob Storer (Pg. 11) 2. Finance Committee Linda Thomas (Pg. 14) 3. Hospital Quality Council Mark Johnson 4. Planning Committee Lauree Morton (no meeting) 5. Bartlett Foundation Bob Storer 6. Rainforest Recovery Center Alex Malter (no meeting) B. AD HOC COMMITTEE REPORTS CAMHU update Mark Johnson/Chuck Bill (informational) VIII. IX. MANAGEMENT REPORTS CEO Mr. Bill (Pg. 31) BOARD EDUCATION Quality measures - Bethany Rogers X. PRESIDENT S REPORT XI. EXECUTIVE SESSION Page Board of Directors packet

2 Medical Staff report (Pg. 33) Union negotiation update Ms. Cosgrove XIV. MARCH BOARD CALENDAR (Pg. 35) XV. BOARD COMMENTS AND QUESTIONS ADJOURNMENT Page Board of Directors packet

3 3260 Hospital Drive, Juneau, Alaska Bartlett Regional Hospital Board of Directors Minutes January 27, 2014 Ms. Davis chaired the meeting, calling it to order at 5:15 p.m. Roll call Present Kristen Bomengen, Past President Nancy Davis, Vice President Mary Borthwick Mark Johnson Brenda Knapp Bob Storer, President (by phone) Linda Thomas Alex Malter, MD Lauree Morton Absent None Others present Chuck Bill, CEO Billy Gardner, CNO Jane Sebens, CBJ Law Karen Crane, CBJ Liaison Alan Ulrich, CFO Toni Petrie, Executive Assistant Public participation None Introduction of Brenda Knapp, Bartlett Regional Hospital s newest board member were made. Special order of business: Board Resolution State of Alaska Grant Mr. Ulrich reported. This grant is used for video surveillance equipment to be used on the Mental Health Unit. The grant dollar amount is $25,000. BRH will be paying for any additional funds. The total cost for the enterprise license is $35,000 and the remainder, if the grant is approved, will come out of the operating funds. This equipment would be an upgrade to the existing system. Page Board of Directors packet

4 Ms. Knapp made a MOTION to approve the Board Resolution Ms. Morton seconded and it passed without objection. APPROVAL OF THE MINUTES - Ms. Borthwick made a MOTION to approve the minutes from the December 18, 2014 Board of Directors meeting. Ms. Bomengen seconded and they were approved. OLD BUSINESS: Housing First Project Mr. Bill addressed a handout that was given at the meeting that went over what the impact or benefit would be for the hospital to contribute to this project. The money would be unbudgeted, but there s potential to get some of those monies back through the City, such as cruise ship funds, etc. The Assembly is asking for the hospital to help support their commitment to the project of $1.5 million. Mr. Bill said he is looking for board support on a dollar amount that he can present to the Assembly and he is recommending $100,000. This would be a onetime request from the Assembly. Ms. Thomas made a MOTION to authorize the CEO to approve up to $100,000 for the support of the housing project. Dr. Malter seconded the motion and it was approved by a roll call vote. Ms. Bomengen asked where the funds would come from. Mr. Bill said the general reserves fund. Ms. Thomas said there s enough room in the capital budget as well and asked if that was appropriate. Mr. Ulrich said it would probably come out of operations. Ms. Morton said she feels if our finances are better than we anticipated, we should commit to more than $100,000. Ms. Thomas would like to see a list of all the entities looking for financial support from the hospital and to have a plan that makes sense for the hospital in the long term. Mr. Storer said he could support up to $100,000 right now, but maybe more down the line. He has spoken with Ms. Crane, Mr. Bill and Ms. Thomas regarding the need for the City Manager and Assembly to have a better mutual understanding on our finances. Strategic plan update Mr. Bill gave an overview of the Focus and Execute tool s strategic goals and objections that were set based on the Board s strategic goals set at their retreat. Mr. Bill asked the Board to adopt these goals. Dr. Malter made a MOTION to ratify the strategic objectives the Board came up with at their board retreat. Ms. Morton seconded and it was approved. Page Board of Directors packet

5 NEW BUSINESS: The Board reviewed the CEO goals for evaluation which Ms. Cosgrove, Mr. Storer, Ms. Bomengen and Mr. Bill worked on. Dr. Malter made a MOTION to accept the CEO goals until May Ms. Bomengen seconded and they were approved. Mr. Storer asked the Board to start thinking about next year s goals come spring time, as Mr. Bill s first year will be up in May. An amendment to the Medical Staff rules and regulations revision was reviewed. Dr. Dressel said it is a clarification of an existing policy of On Call Services. The only change was that the initial document said weekends and now holidays were added as well. Ms. Borthwick made a MOTION to approve this amendment. Ms. Bomengen seconded and it was approved. STANDING COMMITTEE REPORTS Executive Committee Mr. Storer reported there has been no update on Hospice and Homecare at this time. Mr. Storer posed a couple issues. The bylaws require all board packet information get out three days in advance and that isn t happening so he has asked for cooperation from each committee chair. Also, he asked the members of the Executive Committee to think about the roles and responsibilities of the committee and if it needs to meet every month or every other month. Ms. Davis also reported that Jane Sebens provided the work that CBJ Law has done for the month of December. The draft committee assignments were reviewed. Finance Committee Ms. Thomas reported the Finance Committee met January 15 th. They received a Meditech update and Mr. Ulrich is working on a calendar of progress for the project. Meditech is back onsite and is expected to be completed before tourist season. They were able to get the cost down on the BAR conversion and the go live date is still scheduled for November 1, They are currently reviewing the Santa Rosa contract for extending the go live date and the impacts it could have. We have until April 1 st to apply for a hardship extension due to our hardware was damaged in route. The stand-alone audit was addressed and Mr. Ulrich is in the process of working with staff on management comments that came out of the audit. Cerner status was discussed in executive session. Page Board of Directors packet

6 The hospital s American Express Credit Card was discussed. There was a large purchasing amount available for credit and the name hadn t been changed from the prior CFO name. Mr. Bill and Mr. Ulrich are working with CBJ on what they are using and the potentials of the hospital going the same route. There was a calendar handed out that will prepare for the budget with dates already set and what will occur during those meetings. The December financial statements were reviewed (see attached). Ms. Thomas gave a summary of the finances. Ms. Thomas asked Mr. Ulrich to give the Board an estimate of what our financial status will be by the end of the fiscal year. Mr. Ulrich will provide the Board with a timeline and will include projected results for 2015 and also the assumptions going into the 2016 budget. Stryker Navigation System lease The Finance Committee approved this contract based on final legal review. The current system we are using is obsolete and the company is allowing us to remain in the trade-in program. Ms. Thomas made a MOTION to approve the Stryker Navigation System lease, pending the final legal review and administration moving forward when that is complete. Ms. Bomengen seconded and it was approved by a roll call vote. Quality Starting January 2015, the committee has moved into two separate committees. The Hospital Quality Council will meet monthly and the Board Quality Committee will be a 3 person committee with Mark Johnson, Mary Borthwick and Nancy Davis and they will meet quarterly and in advance of the large quality report to the full board. Bartlett Foundation Mr. Storer reported that they have already started work on the Seafood Gala. The other things talked about were the Fahrenkamp Golf Tournament that is help in the Capitol Building each year. There is an auction the night before the tournament. The Foundation is moving their office to another location that will be more suitable. They applied for the Adopt a Road Project to help get their name out. The Avista Corporation gave the Foundation a $12,000 grant, and the Foundation gave representatives of the corporation a walk-through of the areas in the hospital where the Foundation has helped with equipment etc. by raising money for the hospital. The Foundation had a lengthy discussion on the gift shop and how to keep it from losing money. Rainforest Recovery Center Dr. Malter reported. There was an election of officers. Joe Zuboff will remain Chair and John Young will be the Vice-Chair. The group is Page Board of Directors packet

7 concerned about the budget cuts that will come out of DHSS and how that will impact the services of Rainforest Recovery Center. AD HOC COMMITTEE REPORTS Mr. Bill reported that a lot of work is being done on the CAMHU. We are moving forward with a gap needs analysis. We put together a grant application for support from the Mental Health Trust. After getting feedback that we needed to separate the two processes and resubmit the grant, a grant was approved today for $25,000. We are in the process of developing an RFP with CBJ for the needs analysis. We will be soliciting for a group to do a business plan to work together for the feasibility plan and the needs analysis. That will be a separate RFP process. We have gotten recommendations for three consulting groups. They were appreciative of the hospital s effort. CEO report Mr. Bill reported on his recent trip to D.C. with Kristen Bomengen. He didn t feel there was a lot of traction with the Bill regarding the Rural Demonstration Project. There needs to be more follow-up. We will fall out at the end of June if we don t get it passed by this March. It means $3-4 million dollars from our bottom line. Ms. Thomas asked if it would be worthwhile going to our local representatives. Mr. Bill said he and Becky Hultberg (ASHNHA) met with Representative Cathy Munoz and asked for a letter of support which she gave them. Ms. Bomengen said it wouldn t hurt to coordinate efforts with the other hospitals that will be affected. Mr. Bill said that he s been driving one of the hospital s jeeps and he would like to lease the vehicle and keep some cash flow coming to the organization. It s market competitive. He s been working with Ms. Cosgrove and the CFO on the agreement. 5 minute break 7:21 p.m. Back in session at 7:30 p.m. Our Ad Hoc recruiting committee is moving forward to recruit an additional primary care provider in conjunction with Family Practice. There were representatives with people from all the clinics and they were supportive of the hospitals effort. We would help with relocation and student loans. The maximum dollar amount would be $60,000. Ms. Borthwick made a MOTION to approve up to $60,000 to recruit a primary care provider. Ms. Morton seconded. Dr. Malter recused himself from the voting due to conflict of interest. Motion passed with one abstention. Mr. Bill announced we have a recruited a child psychiatrist and he will be starting September 1, Page Board of Directors packet

8 President s report Mr. Storer reported he met with every board member one-on-one to see what their interests are and what committees they are interested in. He would like to meet with everyone one on one at least quarterly. He suggested having a group get together to discuss the Rural Demonstration Project and he has a number of thoughts on where to go if there is interest. Ms. Borthwick made a MOTION to go into executive session at 7:41 p.m., to discuss matters which are both confidential by law (Medical Staff) and matters which could have an adverse effect on the finances of the hospital (CERNER) Mr. Johnson seconded and it was approved. Out of executive session 8:05 p.m. Ms. Bomengen made a MOTION to approve the credentialing report and extend the meeting to 9:00 p.m. Ms. Borthwick seconded and it was approved. Back in executive session to continue discussions which could have an adverse effect on the finances of the hospital at 8:06 p.m. Out of executive session at 8:45 p.m. The February calendar was reviewed. Ms. Davis recognized the memorial service for Eileen Jones, a long term employee of the hospital who recently passed. The staff held a nice service for her in the main hospital. Adjourned at 8:50 p.m. Page Board of Directors packet

9 TOPIC: CEO Performance Evaluation Criteria for May 12, 2014 May 11, 2015 Rating Period Information Only Discussion XX Action Date: February 17, 2015 Executive Summary: The Chief Executive Officer performance evaluation will be due on or about May 12, The BRH Board needs to establish the performance evaluation criteria that the CEO will be rated against and to agree on the process to be used to capture performance feedback. General Performance Criteria: The initial criteria below were drafted by the BRH board in previous CEO evaluation efforts. The criteria have been reviewed and remain relevant. 1 Provides effective leadership implementing the mission and goals of the hospital. 2 Recommends changes and evaluates opportunities for development consistent with the Board's objectives 3 Coordinates effectively with the board, med staff, and personnel to address the community's health care needs 4 Clearly communicates goals, objectives, and proposals for change to board, med staff and personnel. 5 Promotes effective programs to ensure quality care and compliance with regulatory agencies 6 Effectively represents the hospital in its relationships with other health organizations, government agencies, and third party payers 7 Actively promotes the positive reputation and perception of the hospital in the community 8 Monitors trends and changes in the hospital environment to advise and propose the best response 9 Effectively analyzes situations in the hospital and determines good solutions 10 Proposes realistic financial goals and effective means to achieve them Page Board of Directors packet

10 11 Ensures appropriate financial systems are maintained and exercises effective control of operations 12 Promotes teamwork and cooperation amongst hospital and medical staff 13 Ensures that the hospital meets high clinical standards and achieves strong quality outcomes In addition, the board will want to review the performance bonus criteria previously adopted and determine during the overall performance evaluation process if the criteria have been met. This section should include an opportunity for board members to comment in a narrative fashion. Finally, performance criteria for the CEO bonus structure for the next rating period should be identified and discussed with the CEO when the performance evaluation is delivered so goals and expectations are clearly outlined for the upcoming rating period. Process: Each area should be evaluated on a scale of 1 to 7 and board members should have a chance to comment on each area to provide further information on what observations they have regarding that CEO s performance in that area. In addition, the CEO should be provided the opportunity to rate himself and provide feedback on his accomplishments in these areas. I recommend that the BRH HR Department act as the central collection site to gather data and prepare an aggregate report for the Board s use. Proposed Timeline: February 17 March 26 April April 23 April 27 May 1 May 4 May May 28 Board approves Performance Criteria for this rating period. Special Board meeting to discuss drafts performance bonus criteria for next rating period. Board evaluates CEO s performance on general performance criteria for this rating period. Full board reviews and approves performance bonus criteria for next rating period. If needed to conclude HR Department collects data and prepares aggregate report for board use. Special board meeting to prepare CEO evaluation. President and Vice President meet with CEO to discuss the performance evaluation (most likely). If action is required at Board meeting on any item related to the CEO evaluation, it can be included on the agenda for this meeting. Page Board of Directors packet

11 3260 Hospital Drive, Juneau, Alaska Called to order 12:04 p.m., by Bob Storer Bartlett Regional Hospital Executive Committee Minutes February 2, 2015 Attendance: Bob Storer, President, Nancy Davis, Vice-President, Mary Borthwick, Secretary, Kristen Bomengen, Past President, Brenda Knapp, Mark Johnson, Chuck Bill, CEO, Billy Gardner, CNO, Alan Ulrich, CFO, Mila Cosgrove, HR, Jane Sebens, CBJ Law (by phone) and Anita Moffitt, Executive Assistant. Agenda items added Union contract Housing First HR quarterly workforce Mila Cosgrove APPROVAL OF THE MINUTES Kristen Bomengen made a MOTION to approve the minutes from the January 5, 2015 Executive Committee. Ms. Borthwick seconded and they were approved. Meditech update Mr. Ulrich reported the training continues. Santa Rosa will be back onsite next week and he and Mr. Bill will be meeting with them to discuss amendments to the contract. Mr. Bill reported that the physician champions are on board. Mimi Benjamin, MD has agreed to participate instead of Dr. Kim as his call burden is too great to continue. Greg Dostal, MD, is champion on the surgical side, Carlton Heine, MD, Chief of staff will be supporting overall. Mr. Bill said CMS is anticipating realigning the meaningful use date, which would push us back to where we could we could qualify. CBJ Law report The report was reviewed. Ms. Sebens said we have engaged in legal counsel for the CERNER issue. CBJ Legal Department and Dick Monkman are preparing documentation to send to them. CAMHU Mr. Bill said we received notice from the Mental Health Trust that they will be funding the feasibility gap study for $25,000. We have solicited RFP s with CBJ. Once that analysis is complete, then we can talk about going to the next step, feasibility study itself and we have until the end of May to get that accomplished. Mr. Johnson posed the question of getting the Ad hoc committee together before the study is complete. Mr. Bill thought that would be a good idea. Page Board of Directors packet

12 Hospitalist Mr. Bill said we were able to corral most of the primary care doctors to discuss what they would like to see have happen and who is committed to participate. In that discussion, it was quite clear that Valley Medical in particular still wants to follow their own patients, which moves it from a hospitalist program to a no doc program. Mr. Bill and Mr. Ulrich are currently looking at the numbers to see what the financial feasibility will look like. Credit card update Mr. Ulrich reported that the card has yet to be canceled due to outstanding reservations the credit card is being used for and didn t want anyone to be jeopardized during travel by canceling it until something else was in place. He has been working with CBJ with the program they use. Ms. Bomengen would like to take some action. Mr. Ulrich recommended getting a new credit card in Mr. Bill s name. Ms. Borthwick made a MOTION to get a new credit card in Mr. Bill s name with a $50,000 credit limit. Ms. Bomengen seconded and it was approved. Workforce update Ms. Cosgrove handed out the second quarter of the workforce report. It lists new hires, turnovers, and (hospital) contractors/travelers. It also includes hard recruiting vacancies. Union negotiations Ms. Cosgrove said things are going well. All of the articles in the handbook have been opened up and are being reviewed. Also discussed was the Classification and Compensation study and what this could mean for the negotiations and to the hospital. Housing First Mr. Storer expressed our CBJ Liaison s disappointment with the dollar amount the Board agreed upon to assist the City with the Housing First Project. He would like to have the Board to do more due diligence and discuss this again at the February board meeting. The dollar amount may remain the same, but further discussion is needed. Mr. Storer has asked Ms. Thomas to work with the Board on this. Ms. Davis asked if other City entities are being asked to help fund this project. Mr. Storer said the City committed to $1.5 and they are hoping to get some of those funds from several areas. Mr. Storer mentioned the Assembly, the City Manager and the Board need to get together so there is a mutual understanding of the hospital s finances. Bylaws Mr. Storer said our bylaws state that we are to have packets out three days in advance and that is not occurring. If it s not going to happen, then it needs to come out of the bylaws. CEO incentive goals were reviewed and there were discussions if they would be paid out as they occur or after the one year evaluation. Mr. Storer suggested working with Ms. Cosgrove on framework and a timeline bring it to the February meeting so people are thinking about it and can make comments before the March meeting. At the March meeting, there will be a specific product for everyone to rate in time for the April meeting. Budget Mr. Ulrich handed out a proposed budget calendar. He is working on getting information relative to the assumptions and some of the calculations that are part of it. Information has gone out to the directors for them to work on their parts. The goal is to have Page Board of Directors packet

13 something to the City by the April 1, 2015 deadline, which will require the Board to review it and approve it at the March meeting. SEARHC Mr. Bill reported that he was able to meet with Charles Clement and talk about opportunities to work on things. They will be meeting on a monthly basis to determine ways to help each other. Their organization is running into the same concerns from their providers in hospital coverage, etc., so there might be opportunities for us to work together in the hospitalist program. Mr. Storer asked if we aren t successful this year with the demonstration project, is there an option to continue to pursue it next year. Mr. Bill said there are programs at various organizations that are developed with the expectation of the current funding. If the funding goes away, some challenging decisions will have to be made that will have longer lasting impacts then just a year. Jeep Lease Mr. Ulrich reported the MOA was forwarded to CBJ Law and Risk Management to review. There is no way to have private insurance on the vehicle, due to it being a CBJ vehicle. The vehicles were purchased initially for courier services and for locums, but the City is still liable regardless who drives it. Mr. Bill said Administration will bring a recommendation back to the Executive Committee in March. Ms. Davis said she received a call from Hospice regarding the safe sitter we use and she directed them to call Mr. Gardner on moving forward. Ms. Borthwick made a MOTION to go into executive session at 1:52 p.m., to discuss matters which are confidential by law. Ms. Bomengen seconded and it was approved. Out of executive session at 2:08 p.m., no action was taken. Page Board of Directors packet

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32 February 2015 Monthly CEO report Bartlett Regional Hospital Chuck Bill The intent of this report is to highlight, for the board of directors and other interested parties, the activities undertaken and top priorities addressed by the CEO and the Senior Leadership Team in the prior month. Quality & Patient Safety: Department quality initiative, Hot Topic Poster contest underway, Education to be provided at the February board meeting. Employees: Annual recognition dinner set for April 4, The Board is invited (with guest). Dr. Pappenheim s last day was February 10, Community: Continue to participate in Rotary & Chamber. Worked with ASHNHA, CBJ Lobbyist Katie Kachel and other Alaska Delegates to drum up Medicare Rural Demonstration project extension support on the Senate. Senator Grassley (Iowa) and Senator Murkowski (Alaska) have agreed to co-sponsor. We are working on finding a Democrat to also co-sponsor. Overall, it is looking very promising. CAMHU - gap/needs analysis grant was approved by the Alaska Mental Health Trust. An RFP went out and we only received feedback from one group, which was the McDowell Group who requested more time then the allotted timeframe. They are submitting a proposal with that extended timeframe. Senator Dan Sullivan will be here to tour the hospital on 2/19/2015. Medical Staff: Interviewed another pediatrician and another psychiatrist as part of our recruitment effort. Began working with Family Practice to recruit another physician to their group. Continue working towards hospitalist model. Finance/Systems: Meditech work continues. FY16 budget department underway. Infrastructure clean up/control of credit cards nearly complete. Board: Finance 101/budget work session initiated. Board governance education scheduled for February and March. Page Board of Directors packet

33 Credentials Committee Hospital Privileges for Board of Director s Consideration Tuesday, February 17, :15 p.m. Robert F. Valliant Center Boardroom REAPPOINTMENTS TO THE MEDICAL STAFF: Name Category Privileges In 1. Noble Anderson, MD Active Family Medicine w/ob Dr. Noble E. Anderson graduated from the Temple University School of Medicine in Dr. Anderson is a board certified family medicine w/ob physician for SEARHC - Spruce. 2. Jessica L. Arasmith, MD Locum Tenens Pediatrics/Newborn Dr. Jessica L. Arasmith graduated from the University of Washington School of Medicine in Dr. Arasmith is a board certified pediatrician who providers locum tenens services for Rainforest Pediatrics. 3. Lawrence Dardick, MD Consulting Radiation Oncology Dr Lawrence R. Dardick graduated from the University of Missouri Columbia School of Medicine in Dr Dardick is a board certified radiation oncology physician for Mountain Radiation Oncology in Reno, NV. 4. William Hammel, MD Consulting Anesthesia Dr William H. Hammel graduated from the University of Nebraska Medical Center in Dr Hammel is a board certified anesthesiologist physician in Anchorage. REQUEST FOR ADDITIONAL/EXPANDED PRIVILEGES: 1. Matthew Taintor, MD (Exercise Stress Treadmill Test/Nuclear Stress Tests) PHYSICIAN ASSISTANT STUDENT: 1. Stephanie Shippy, PAS (University of Washington MEDEX BRH Emergency Department; Evaluate/Treat Patients, Inpatient H&P Under Direct Supervision of the Supervising Physician and Per Policy ) CHANGE OF STATUS: 1. Mary Ellen Arvold, PNP (Allied Health Professional to Access to Services) 2. April Sapp, FNP (Allied Health Professional to Access to Services) MEDICAL RESIDENT: 1. Cassie Iutzi, MD, MD (University of California Davis/SEARHC; Family Medicine w/ob) Page Board of Directors packet

34 TELEMEDICINE: 1. Ravinder Shergill, MD Telemedicine The Alaska Hospitalist Group; eicu) Dr. Ravinder P. Shergill graduated from Mahindra University College in Punjabi in Dr. Shergill is a board certified internal medicine physician for the Alaska Hospitalist Group in Anchorage. LOCUM TENENS: 1. Kristi A. Nix, MD Locum Tenens Pediatrics/Newboarn Dr. Kristi A. Nix graduated from the University of Chicago School of Medicine in Dr. Nix is a physician who is board certified pediatrician and will be providing services to Rainforest Pediatrics. Y:\Medical Staff\BOD\2015\ BOD Summary.doc Page Board of Directors packet

35 March 2015 Sunday Monday Tuesday Wednesday Thursday Friday Saturday 1 2 CANCELLED - Executive Committee :00 Credentials Committee BR Quality Committee BR :15 Finance Committee BR :15 Board of Directors BR :00 Special Board Mtg. BR Page Board of Directors packet