LemhiWeb

 

January 24, 2012

 

MINUTES

 

MEMBERS PRESENT:          Dennis Lile, Chairman

Shayne Holmes, Vice Chairman

Ryan Allen, Secretary/Treasurer

Mike Ries

Kimberly Nelson

Kristin Troy

Mark Oliverson, DMD

Ex Officio:

                                                Jeff Hill, CEO

Rick Snyder, Lemhi County Commissioner

Adam Deutchman, MD, FACS

 

MEMBERS ABSENT:                        Linda Price

 

OTHERS PRESENT:              Donna Hayden, Quality Assurance Manager

Kathryn Leavitt, CCO/Human Resources Director

Bill Henning, QHR Regional Vice President

Abner King, CIO

Greg Hexem, CFO

Stephanie Orr, CNO

Minutes recorded by Libby Brittain, Administration Manager

 

CALL TO ORDER:                 The meeting was called to order at 4:03 p.m. by D. Lile, Chairman.

 

EXECUTIVE SESSION:        MOTION:  Motion was made by S. Holmes, seconded by M. Ries to move into executive session under Idaho Code 67-2345(a)(b) to discuss: HIPAA, Compliance, and Human Resources Reports; Provider Contract; and CEO evaluation. Motion carried unanimously by roll call.  The general session reconvened at 4:37 p.m.

 

AGENDA AMENDMENT:    MOTION: Motion was made by K. Nelson, seconded by R. Allen to amend the agenda to postpone the Human Resources and Quarterly Compliance Presentations until the February meeting. Motion carried unanimously.

 

PUBLIC COMMENT:             None.

 

STRATEGIC PLAN UPDATE &

ANNUAL BUSINESS PLAN:J. Hill presented the 2012 Annual Business Plan which included: SMMC’s Organizational Structure; Service area definition and market factors affecting SMMC; Patient volume statistics; and, a review of SMMC’s Strategic Plan and an update on specific initiatives.

 

                                                MOTION: Motion was made by R. Allen, seconded by M. Ries to approve the 2012 Annual Business Plan as presented. Motion carried unanimously.

 

CONSENT CALENDAR:       Included in the consent calendar were the following items:

• Minutes from the November 22, 2011 meeting;
• CEO Report;
• Patient Care Services Report;
• Ancillary Services Report; and
• Medical Staff Report, including:
  • Pharmacy Department Policy & Procedure Manual
  • Taro Aikawa, MD: Provisional Privileges Teleradiology, Radiology
  • Gregory Kenyherz, MD: Provisional Privileges Teleradiology, Radiology
  • Thomas Spinuzza, MD: Provisional Privileges Teleradiology, Radiology

                                               

                                                MOTION:  Motion was made by M. Ries, seconded by K. Nelson to approve the consent calendar as presented. Motion carried unanimously.

 

J. Hill reported that the Foundation has set an annual giving campaign fundraising goal of $75,000 and donations have been designated toward the purchase of a Digital Mammography System. J. Hill noted that total donations and pledges received to-date totaled $64,000.

 

                                                M. Ries inquired as to the number of Tele-radiologists being credentialed and approved for Medical Staff. A. Deutchman, MD explained that the tele-radiologists are sub-contracted through Medical Imaging Associates of Idaho Falls. In addition, it was noted that there is frequent turnover. J. Hill clarified that while tele-radiologists are off-site, SMMC has a radiologist onsite once per week.

                                               

EXECUTIVE COMMITTEE

REPORT:                                D. Lile reported that the Executive Committee met on January 6 to discuss Board goals for the 2012 year, including: Board member succession planning and recruitment process; CEO evaluation criteria; the need for board bylaws to be updated; committee assignments; special committee for an annual assessment of QHR; Board member code of conduct and conflict of interest statements; and a provider contract.

 

                                                A. Deutchman inquired if there is a mechanism to highlight needs for Board Bylaws as standards change. D. Lile stated that the Bylaws are aligned to Idaho statutes. J. Hill stated that Kim Stanger, SMMC Attorney would review the Bylaws. D. Lile emphasized the need to form a standing committee to keep the Bylaws updated on an annual basis.

                                               

FINANCE

COMMITTEE REPORT:        R. Allen reported that the Finance Committee met on January 18 to review the November and December financial statements.

 

MOTION:Motion was made by R. Allen, seconded by S. Holmes to approve the November and December 2011 Financials.  Motion carried unanimously.

 

Yellowstone Insurance

Exchange:                               R. Allen stated that the Finance Committee recommended that the

Yellowstone Insurance Exchange be approved. R. Allen also noted that there will be a premium discount for the 2013 renewal year when educational requirements have been met.

 

MOTION:Motion was made by R. Allen, seconded by S. Holmes to approve the Yellow Insurance Exchange Premium for calendar year 2012.  Motion carried unanimously.

 

QHR Nursing Productivity

Support Agreement:                S. Orr stated that within the nursing productivity support agreement, staffing would be evaluated within the Surgery, Emergency and OB departments in addition to the Medical/Surgical department. S. Orr stated that the nursing productivity assessment will include a review of the current staffing model in place and provide alternative staffing models to improve efficiency. J. Hill stated that SMMC has received a grant in the amount of $3,500 to assist with the nursing productivity assessment costs. R. Allen stated that there are upfront costs for the assessment but that SMMC needs to evaluate the long-term cost savings. R. Allen noted that there was a concern regarding the disclaimer language within the agreement and reported that Kim Stanger, SMMC Attorney reviewed the disclaimer and was comfortable with it.

 

MOTION:Motion was made by K. Nelson, seconded by K. Troy to approve the QHR Nursing Productivity Support Agreement as presented.  Motion carried unanimously.

 

QHR Provider Coding Review

and Education:                        J. Hill explained that within the QHR Administrative Services Agreement SMMC is allotted a certain number of assessments. One of the assessments completed reviewed coding for clinic outpatients. The report resulting from the assessment recommended to conduct a detailed outpatient coding review to include the clinic, emergency department, and outpatient specialty clinic. The outpatient coding assessment would include a detailed review of 130 records and provide education for providers. In addition, it will help providers prepare for ICD-10.

 

                                                A. Deutchman, MD emphasized the importance of reviewing provider documentation and coding for compliance. K. Nelson stated that she has completed some research on the topic of clinic documentation and understands that documentation will be critical for the success of hospitals.

 

MOTION:Motion was made by K. Nelson, seconded by M. Ries to approve the QHR Provider Coding Review and Education as presented.  Motion carried unanimously.

 

Patient Financial Services and Finance

Policy & Procedure Manuals:R. Allen reported that he and D. Lile met and reviewed both the Patient

Financial Services and Finance Policy and Procedure Manuals. It was the recommendation to approve both manuals.

 

MOTION:Motion was made by R. Allen, seconded by S. Holmes to approve the Patient Financial Services Policy & Procedure Manual as presented.  Motion carried unanimously.

 

MOTION:Motion was made by R. Allen, seconded by M. Oliverson to approve the Finance Policy & Procedure Manual as presented.  Motion carried unanimously.

 

QHR Inpatient Coding Audit

Management Action Plan:       R. Allen reviewed the management action plan resulting from the inpatient

coding audit. It was noted that there were nine action items recommended, seven of the action items have been completed. G. Hexem stated that there are two outstanding items which are in progress: 1) Annual coding audit, and 2) plan for implementation of ICD-10 set for October 1, 2013. QHR Inpatient Coding Audit Management Action Plan

 

Finance Training:                   G. Hexem offered a finance training opportunity for board members.

K. Nelson, K. Troy, S. Holmes, M. Oliverson, and D. Lile expressed interest in attending.

 

BOARD EDUCATION:          K. Nelson and K. Troy presented information regarding the QHR Board Essentials Workshop attended on December 1-2, including the following topics:

• Governance Roles & Responsibilities (e.g. importance of accountability of board members; responsibility, fiduciary duty, and quality of care patients receive in the hospital);
• Unraveling the Mystery of Financial Statements;
• How we get Paid:
• Overview of the Hospital Revenue Cycle;
• Understanding Accreditation and the Board’s Role in Quality Improvement (QI);
• Strategic Planning in the Post-Health Reform Era; Aligning the Goals of the Board & Medical Staff;
• Compliance: The Board’s Responsibility;
• The Hospital Board Member’s Role in the Community; and,
• Responsibilities of Hospital Governing Boards

 

OTHER BUSINESS:              

Erin Swenson, MD

Physician Contract:                 MOTION: Motion was made by S. Holmes, seconded by M. Ries to approve the Physician Contract for Erin Swenson, MD as discussed during Executive Session.  Motion carried unanimously.

 

CEO Evaluation Matrix:          B. Henning stated that based upon feedback received, he would present a final matrix for the board to review and approve at the February meeting.

 

Standing Committee

Assignments:                            D. Lile reviewed and appointed the following board members to the standing committees:

Finance: R. Allen, Chair; K. Nelson; J. Proksch, Community Member; J. Hill; S. Orr; A. King; G. Hexem. It was noted that R. Allen would retain the chairman position as the Board Secretary/Treasurer.

 

                                                Quality & Credentialing: M. Ries; S. Holmes; M. Oliverson, DMD; A. Deutchman, MD; D. Hayden; J. Hill; S. Orr.

 

                                                Goals & Community Health: L. Price; K. Troy; J. Wolters, Community Member; J. Hill; S. Orr; A. King; G. Hexem

 

Joint Conference: D. Lile; S. Holmes; R. Allen; A. Deutchman, MD; D. Zavotsky; MD; R. Natelson, MD; J. Hill, Facilitator

 

MOTION:Motion was made by S. Holmes, seconded by M. Ries to approve the standing committees and membership as appointed. Motion carried unanimously.

 

MOTION:Motion was made by S. Holmes, seconded by K. Troy to appoint M. Ries as the chair of the Quality & Credentialing committee. Motion carried unanimously.

 

MOTION:Motion was made by S. Holmes, seconded by K. Nelson to appoint K. Troy as the chair of the Goals & Community Health committee. Motion carried unanimously.

 

March 2012 Board

Meeting:                                  It was the general consensus of the board to reschedule the March 27 meeting to Thursday, April 5.

 

Other:                                      J. Hill noted that next week he will be in Washington DC as part of the National Rural Health Association, Rural Health Congress.

 

B. Henning informed the board that there will be a QHR Trustee Conference in Denver on May 3-4 with Board Leader Training to be held on May 2. In addition, there will be a QHR Regional meeting in Henderson, NV for CEO’s and CFO’s on March 8-9.

 

B. Henning reported that a Wage & Salary review for staff and an Emergency Department Assessment is scheduled for this year.

 

B. Henning stated that he would send an ICD-10 toolkit to assist with the transition to new coding standards.

 

ADJOURNMENT:                  Meeting was adjourned at 6:46 p.m.

 

 

                                                                                                                                                           

                                                                                                            Dennis Lile, Chairman