Commissioner Ely opened the meeting for public comment. Several members of the public provided comments regarding the proposed affiliation.

Transcription

1 August 15, 2013 The regular meeting of the Board of Commissioners for Island Hospital was called to order by President Ely at 7:15a.m.in the Cypress Room of Island Hospital. Those present were Commissioners Lynne Lang, Ph.D., Chip Bogosian, MD, Paul Maughan, Ph.D, Buzz Ely, MD, and Jan Iversen. Also present were Vince Oliver, CEO; Elise Cutter, CFO; Lois Pate, RN, CNO: Scott Harrison, MD, Chief of Staff; Kara Tippett, Executive Assistant; Sandra Marin, RN, Coordinator, Quality; Dennis Richards, Director, Community Relations; Bernadette Stanek, Foundation Development Director; Kay Steiner, Revenue Cycle Development Director; and Jacob Buckenmeyer, Anacortes American. Commissioner Ely opened the meeting for public comment. Several members of the public provided comments regarding the proposed affiliation. CONSENT AGENDA: Approval of the Board Warrants After review, Commissioner Maughan made a motion to approve the Consent Agenda. Commissioner Iversen seconded the motion. Commissioners Lang, Bogosian, Maughan, Iversen and Ely all voted aye and the motion carried. BOARD QUALITY & PATIENT SAFETY REPORT Commissioner Iversen welcomed Dr. Harrison to the meeting. Medical Staff Meeting Summaries OB/ Peds Committee Urinary Catheter Removal nursing Protocol: The guidelines for urinary catheter removal states the catheter should be taken out within 24 hours. The purpose of the proposed protocol is to assist the RN s in the decision making process in respect to the removal of a urinary catheter. The group agreed that the RN s should not pull the catheter without a physician s order. Labor Induction/Appropriateness: The potential risks and benefits of labor induction and the date of induction will be included on hospital forms. Labor Management Bundle: This management bundle will be used to evaluate the hospital for primary C-sections under 39 weeks. This will require more detailed documentation by the providers. QA Committee Illegible Signatures: There have been concerns regarding illegible physician signatures. It is a CMS requirement that physician signatures be legible. If they are not, the physician may print his/her name below their signature or use a stamp with their printed name below their signature. H&P Documentation: In order to cut down or avoid RACs denials, providers must document why they feel a patient meets inpatient status.

2 Credentials Committee CME Requirements Rules & Regulations: A new recommendation from DNV is that we track CME at initial and reappointment cycles. The volume of documentation being generated for this requirement is very large. It is recommended that we follow the requirements the state has for licensure. The committee has voted to approve the addition to the Rules and Regulations. Credentials List: After review, Commissioner Maughan made a motion to approve the Credentials list. Commissioner Bogosian seconded the motion. Commissioners, Lang, Maughan, Bogosian, Iversen, and Ely all voted aye and the motion carried. Quality Management Review Summary Anita McCoy presented information from the Quality Management Review meeting. Patient Satisfaction: Home Health 1. Our overall Home Health patient satisfaction decreased by 1%- from 84% to 83%. This was based on a sample group of depending on the question asked. When asked if patients would recommend our agency 83% said yes. 2. In our region, Island Hospital meets or surpasses other hospital and agency Home Health in patient satisfaction in all areas. DNV: Tobacco Free Campus 1. Our smoking policy has been changed to reflect that Island Hospital is now a tobacco free campus. There is a subcommittee working on the implementation. A Q&A handout to address questions asked by staff has been developed and will be placed on the Intranet and attached to the policy in PolicyTech. 2. Human Resources is considering adding a question to applications regarding applicants smoking status. If an applicant smokes, it would be required they agree to enter smoking cessation and quit within 6 months of employment. In 2014, employees with smokers in their home will have an increased premium for health insurance. 3. There has been concern regarding our lack of a designated smoking area as many staff members have moved to smoke in the street. This presents a community image issue. Expired Licenses and Certifications Licenses and certifications are being reviewed. If a staff member s license is not current their badge will be turned off. Certifications are being reviewed to see if it is a requirement for their job function. If it is a job requirement, we are checking to ensure that it is on the job description. Currently 67 staff members are missing a certification. Diverts: July Diverts: There were 6 diverts in July. Acute care diverted 4 patients and ICU diverted 2 patients- all due to no beds.

3 FINANCE UPDATE: Elise Cutter reported on the July 2013 financial statements with the Committee and highlighted the following as significant items: Patient Volumes Inpatient admissions for year to date July 2013 were 1,768 against a budget of 1,799 and 1,801 for year to date July The average daily census year to date July 2013 was 28.6 patients compared to 27.7 budgeted and 27.6 for year to date July Surgery minutes year to date July 2013 were 6% less than budget and 4% below year to date July Emergency Room visits year to date were.3% less than budgeted and 1.1% more than year to date July The total number of outpatient visits was 3.9% less than budgeted and 9.1% more than year to date July 2012, physician clinic visits were 11.7% less than budgeted and 6.8% more than year to date July Rural health clinic visits were 2.5% less than budget and 6.6% more than year to date July Balance Sheet The hospital collected $7.6 million in July and paid out $6.9 million which resulted in a increase of day s cash on hand to 89.9 from 86.7 at the end of June. The days in Accounts Receivable decreased to 42.4 from 44.9 days at the end of June. Cash and cash equivalents decreased $974,000 from the end of Net Revenue Net revenue for July 2013 was $6.8 million with actual collection rate of 40.6% which was below the budgeted 41.4%. Bad Debt was $35,000 above the budgeted amount for July and $258,000 above the budget year to date. Operating expenses Year to date total expenses are $835,000 under budget or 2%. The total number of FTE s for July 2013 were 523 which is 1 more than budgeted and 7 more than The Hospital recorded a net operating loss for July 2013 of $84,000 or -1.2% versus the budgeted income of $81,000 or 1.1%. The excess margin for July 2013 is a loss of $34,000 versus budgeted excess of $157,000 and year to date excess margin of -$498,000 versus the budgeted year to date of $552,000. STRATEGY UPDATE: Orcas Island Medical Center: Vince reported that Dr. Camille Fleming has signed her agreement and will be here the beginning of the year. Island Internal Medicine: Dr. Yvonne Naughton a pediatrician has joined IIM. She has joined the hospital call list. IH2035 Update: There will be a final meeting in Anacortes the beginning of September. Joint Board Discussions: The group met last night and will be scheduling another meeting before the end of August. Hospital Reclassification Project: Vince noted this project is complete. They will work with Dale Baker on other possibilities. Lipidology: Vince reported with school starting again work will resume on this.

4 MIN-NS EHR: Vince noted that MIN-NS will be more a part of the affiliation process Hospital Service Club Talks: Vince continues to talk with various groups in the community. Surgery Project: A report will be provided on this when there is a more specific plan. OLD BUSINESS: None NEW BUSINESS: Central Registration Project: Kay Steiner, Director of Revenue Cycle Management is the project manager for the central registration redesign. Kay updated the group on the status of the project and the plan for it. Island Hospital Foundation: Bernadette reported on a very successful Golf Classic. Nancy Rytand has joined the Foundation as the Development Assistant. Bernadette spoke about working more on the Anacortes School District Intervention Program and the importance of continuing to build this program. Commissioners Calendar: Vince reviewed the September Board of Commissioners Calendar. Commissioner Ely suggested a Working Board Meeting for August 22 nd, the meeting will be from 5:00pm-7:30pm. The meeting is open to the public, there is no public comment. There will be a Joint Board Meeting on August 29 th at noon, location to be determined. Commissioner Compensation: Commissioner Maughan explained that every five years the compensation is reviewed. Recently the amount was increased to $ per meeting/day. He suggested the Board accept the increase and each Commissioner can choose from there if they will take the increase, donate it, etc. Commissioner Compensation Approval: After review Commissioner Bogosian made a motion to approve the Compensation. Commissioner Lang seconded the motion. Commissioners, Maughan, Bogosian, Lang, Iversen, and Ely all voted aye and the motion carried. Yvonne Naughton, MD Employment Agreement Vince discussed the agreement with the group. Yvonne Naughton, Employment Agreement approval: After review, Commissioner Maughan made a motion to approve Yvonne Naughton s Employment Agreement. Commissioner Iversen seconded the motion. Commissioners, Lang, Maughan, Bogosian, Iversen, and Ely all voted aye and the motion carried.

5 Resolution 1890 Supplemental Executive Retirement Plan(SERP) Elise explained the changes in the plan, they were regulatory changes and they need to find a new vehicle for the program. Resolution 1890 approval: After review, Commissioner Bogosian made a motion to approve Resolution Commissioner Iversen seconded the motion. Commissioners, Lang, Maughan, Bogosian, Iversen, and Ely all voted aye and the motion carried. EXECUTIVE SESSION: None ADJOURNMENT: There being no further business, Commissioner Ely called for the meeting to be adjourned at 8:59 a.m. _ Buzz Ely, M.D., President/Commissioner Jan Iversen, Secretary/Commissioner Lynne Lang, Ph.D., Commissioner Paul Maughan, Ph.D., Commissioner Chip Bogosian, M.D., Commissioner