UNM Hospital Board of Trustees OPEN SESSION AMENDED AGENDA ... · 11/17/2017 · UNM Hospital Board...

UNM Hospital Board of Trustees OPEN SESSION – AMENDED AGENDA Friday, November 17, 2017 at 9:00 AM

Barbara and Bill Richardson Pavilion Conference Room 1500 I. CALL TO ORDER – Jerry McDowell, Chair, UNM Hospital Board of Trustees II. ANNOUNCEMENTS III. ADOPTION OF AGENDA

IV. CONSENT APPROVAL/INFORMATIONAL AGENDA

Consent/Approval Items (Approval) Kaufman Hall & Associates Stryker / OSIS – OR – Integration and Lighting Upgrade Stryker / Main – OR – Lighting and Boom Upgrade Eco-Tex Healthcare Linen Service Corp Carrie Tingley Hospital (CTH) Re-Roof

V. PUBLIC INPUT

VI. APPROVAL OF THE MINUTES

October 27, UNMH Board of Trustees Meeting Minutes – Michael Chicarelli, DNP, RN, CEN (Approval) VII. OCTOBER ACTION ITEMS

UNMH Management to keep Board of Trustees informed on how the implementation of the Financial Assistance Policy, Discount Program Policy, and Patient Payment Policy is progressing

Sara Frash to invite a couple of DYAD Partners to give a presentation “A Day in the Life” at a future Board of Trustees Meeting

Once finalized, the Physician and Leadership Engagement results along with graphs will be posted on BoardVantage

DYAD partners to be showcased at ME: Leading To Excellence – Dr. Richards will be presenting this information at the next LTE

Efficiency Curve presentation at a future Board of Trustees Meeting – Dr. Perryman Collins

Fontaine will send November date and time of the Quality & Safety Committee Meeting to Board Members

Dr. Crowell to give a condensed version of the Quality Report he presents to the Quality & Safety Committee to the Board of Trustees at a future meeting

Board of Trustee Members to discuss with their committees about having a Board of Trustee representative from their committee make a full recommendation to the Board for approval of items listed on agenda

Scot Sauder to research changing the wording during a motion from “approval” to “acknowledge receipt of” and report his finding to the Board of Trustees

Quality to create a cheat sheet for Board Members in the event The Joint Commission (TJC) requests a Board Member be interviewed during one of their visits to UNMH

UNMH Management to keep Board of Trustees updated on MOU issues as the process moves forward.

UNMH Management to draft an update/report on Larry Gages’s recommendations for Board of Trustees review. Mike Chicarelli and Jerry McDowell will coordinate/review prior to bringing to the Board of Trustees

Dr. Roth’s office will send list of CEO Search Committee Members to Board of Trustees Members VIII. BOARD INITIATIVES

Chairman’s Report – Jerry McDowell, Chair

Larry Gage’s Recommendations – Michael Chicarelli, DNP, RN, CEN

Patient Payment Policy – Michael Chicarelli, DNP, RN, CEN

Mission Excellence Update – Sara Frasch IX. ADMINISTRATIVE REPORTS

Chancellor for Health Sciences - Paul Roth, MD

CEO Report UNM Hospitals – Michael Chicarelli, DNP, RN, CEN

CMO Report UNM Hospitals – Irene Agostini, MD

UNM Board of Regents Update – Michael Chicarelli, DNP, RN, CEN X. COMMITTEE REPORTS

Quality and Safety Committee – Dr. Raymond Loretto

Finance, Audit & Compliance Committee – Terry Horn

Native American Services Committee – Jerry McDowell, Chair XI. OTHER BUSINESS XII. CLOSED SESSION: Vote to close the meeting and to proceed in Closed Session.

a. Discussion and determination where appropriate of limited personnel matters pursuant to Section 10-15-1.H (2), NMSA. b. Discussion and determination, where appropriate, of matters subject to the attorney-client privilege regarding pending or threatened

litigation in which UNMH is or may become a participant pursuant to Section 10-15-1.H (7), NMSA. c. Discussion of matters involving strategic and long-range business plans or trade secrets of UNMH pursuant to Section 10-15-1.H (9),

NMSA. d. Vote to re-open the meeting

XIII. Certification that only those matters described in Agenda Item XII were discussed in Closed Session; consideration of, and action on the specific limited personnel matters discussed in Closed Session.

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Stryker / OSIS – OR – Integration and Lighting Upgrade

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CAPITAL PROJECT APPROVAL

Outpatient Surgical Imaging Services (OSIS) – Operating Room (OR) – Integration and

Lighting Upgrade

November 2017

REQUESTED ACTION:

As required by Section 7.12 of Board of Regents Policy Manual, the New Mexico Higher

Education Department and the New Mexico State Board of Finance, capital project approval is

requested for OSIS – OR – Integration and Lighting Upgrade.

DESCRIPTION:

This project is to replace existing Operating Room surgical light booms in the six Operating

Rooms with new tandem suspension with a Teletom equipment management system / two LED /

Field Point. This will require extensive modifications to the existing structure to support design

loads of new equipment, additional electrical circuits, medical gas modification and the

installation of the new Imagestream system.

RATIONALE REPLACEMENT:

OSIS is fully integrating its 6 Operating Rooms with the Imagestream integration system as well as

replacing lights and booms. The integration system will allow for better patient care and

improvements in using space resources in the OR by having all 6 rooms laparoscopic procedure

capable. This is the Second phase of OR integration which began with the BBRP pediatric OR in

2015. As well the integration allows for the control of equipment from a single terminal and the

uploading of images to the Electronic Medical Record for proper patient documentation. Current

lighting is over 10 years old and does not meet the needs of our surgical faculty performing

procedures. The new lights will reduce cost in maintenance as they are 15-20 year LED systems.

Currently OSIS does over 5,000 outpatient procedures annually and has been growing at a pace

above 6%. This infrastructure is needed to help OSIS keep pace in the quality of care it is able to

provide to the community.

FUNDING:

The total project budget is estimated at $1,698,000 with $1,098,000 funded by UNM Hospital

Capital Equipment Budget and $600,000 funded from the UNM Hospital Renovation Capital

Budget.

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Stryker / Main – OR – Lighting and Boom Upgrade

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UNMH Main – Operating Room (OR) – Lighting and Boom Upgrade

November 2017

REQUESTED ACTION:



requested for UNMH Main – OR – Lighting and Boom Upgrade.

DESCRIPTION:

This project is to replace existing Operating Room surgical lights and booms in the 15 ORs.

This project will require modification to the existing structural supports, additional electrical

circuits as well as medical gas modification.


UNMH Main – OR is in need of replacing lights and booms in its 15 ORs. Current systems are

constantly failing creating surgical delays and costly repairs. Lighting is over 10 years of age in

most ORs. Lighting solution proposed will standardize lights throughout surgical services which

will lead to more cost efficient repair and maintenance in the future. UNMH Main OR currently

houses over ten specialties and the case volume exceeds 10,000 cases annually. Surgical Services

bills out over $250,000,000 of gross revenues for UNMH hospitals. This project will also provide

critical safety items such as drop down lead shield to decrease radiation exposure.

FUNDING:

The total project budget is estimated at $1,570,000 with $970,000 funded by UNM Hospital Capital

Equipment Budget and $600,000 funded from the UNM Hospital Renovation Capital Budget.

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Eco-Tex Healthcare Linen Service Corp

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UNM Hospital Board of Trustees

Recommendation to HSC Committee

November 2017

Approval

1) Eco-Tex Healthcare Linen Service Corp

Ownership: Officers Information:

Eco-Tex Healthcare Linen Service Corp. President and CEO: Randy Bartsch

1115 E 25th Vice President: Bryan Bartsch

Tacoma, WA 98421

Source of Funds: UNM Hospitals Operating Budget

Description: Request an eight year agreement with Eco-Tex Healthcare Laundry Services, Inc. to provide

laundry services for UNM Hospitals through October 31, 2025. UNM Hospital processes approximately

four million pounds of linen annually. Services are provided for all medical laundry including the

following: sheets, pillow cases, blankets, towels, patient gowns and surgical scrubs. Services include in-

hospital soiled linen pick up twice daily, seven days per week. Eco-Tex will provide at no charge linen

management software for computerized tracking and reporting of unit par levels and usage. Additional

services include storage of UNM Hospitals’ pandemic linen supply for emergency requirements. New

agreement pricing is as follows:

Launder and Deliver Clean Linen: $0.354/lb.

Soiled Linen Pick Up: $0.420/lb.

Receive and Breakdown New Linen: $510.00/month

Store Overflow and Pandemic Linen: $10,185.00/ month

Offsite Delivery Fee $ 9,687.00/month

Pricing will be held firm for the first five years of the agreement with subsequent escalators no greater

than the CPI-U Medical Services annual rate capitated at no more than 2.5% and upon mutual written

agreement.

Process: RFP P375-17

RFP Respondents: There were 2 respondents to the RFP:

1. Mission Linen Supply

2. Eco-Tex Healthcare Laundry

Selection Criteria:

The RFP committee members which consisted of Florencio Gallegos, Executive Director of Material

Management, Yvonne Trujillo, Director of Value Analysis & Material Handling and Jessie Montoya,

Distribution Manager reviewed and scored all proposals based on vendor oral presentation, interview and

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written proposal submittals and the vendor determined to bring the best value to UNM Hospitals was

selected via highest score.

Mission Eco Tex

Relevant Experience and References 20.00 29.33

Ability to Perform Services 17.67 29.33

IT Security Plan .50 4.50

Cost 24.00 35.00

62.17 98.17

Contract Term: Initial term of five (5) years with an option to extend for three additional years, not to

exceed eight (8) years.

Termination Provision: Either party may terminate this agreement with 180 days written notice.

Previous Contract: Eco-Tex Healthcare Linen Service Corp.

Previous Term: Eight Years

Previous Contract Amount: $1,928,270

Projected Annual Cost: (Dependent on volumes) $1,910,372

Based on current volumes, the estimated cost savings is $17,898 per year or $89,448 for the initial five

year term.

(2) Kaufman, Hall & Associates LLC

Ownership: Officers Information: 5202 Old Orchard Rd, Suite N700 CEO: Therese Wareham

Skokie, IL

Source of Funds: UNM Hospital Capital Fund

Description: Request approval to purchase from Kaufman, Hall & Associates, LLC (Kaufman) an

Enterprise Wide Health Care Cost Accounting System. This system will provide comprehensive costing

of healthcare services across the UNM Health System.

The system will include the following:

1) Costing of hospital-based as well as professional services;

2) Reporting of costs, productivity, and profitability across the Health System by encounter, by

provider, by third-party payer, by service line, etc.;

3) Allow for source data feeds from multiple patient financial services systems, general ledger

systems, and the UNMH electronic EMR and Population Health Management system; and

4) Allow for import of external claims data from third-party payers or partner providers to allow for

analysis under bundled payment and capitation scenarios. The ideal system will also allow for

flex budgeting and interfacing with the Health System’s operating and capital budgeting tools.

Contract Term: The term of the contract shall not exceed eight (8) years in duration.

Process: RFP P344-16

Respondents:

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1) Kaufman

2) Strat Decision Technology

Previous Contract: N/A

Previous Term: N/A

Previous Contract Amount: N/A

Selection Criteria: The RFP Evaluation Committee members were comprised of:

Bonnie White, Executive Director Finance Planning & Analysis

John-Paul Montoya, Revenue Cycle Director, CRTC Fiscal Services

Rodney F. McNease, Executive Director BH Finance, BHO - Revenue Cycle Ops

Darlene L. Fernandez, Chief Financial Officer of SRMC

Marjorie Goldstein, Vice President Finance and CFO, UNM Medical Group

Selection was based upon highest scores for the following criteria:

Experience, quality, stability, and reputation of the Offeror. 5 Points Possible

IT Security Requirements 5 Points Possible

Product Functionalities 40 Points Possible

Integration/Implementation Work Plan 25 Points Possible

Services, Ongoing Support Model 10 Points Possible

Price Proposal 15 Points Possible

TOTAL 100 Points Possible

Total Cost: $1,410,000

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Carrie Tingley Hospital (CTH) Re-Roof

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Carrie Tingley Hospital – CTH Re-Roof

November 2017

REQUESTED ACTION:



requested for Carrie Tingley Hospital – CTH Re-Roof

DESCRIPTION:

This project is to replace existing failed roofing system. The scope of work is to remove existing

EPDM (Ethylene Propylene Diene Terpolymer) roofing assembly to Deck roofing. Project will

include new insulation, flashings, gutters and downspouts. The new roofing will be topped with

new two-ply field membrane utilizing a base layer and a cap sheet with mineral surface.


The existing roof in the areas of replacement is over 20 years of age. There are many failed areas

that have been repaired repeatedly to extend the life of the roof. In that process many hours have

been spent replacing wet ceiling tiles as well as spot repairs. New roof will carry a 30 year high

performance built up roofing system no dollar limit warranty.

FUNDING:

The total project budget is estimated at $380,000 from the UNM Hospital Capital Budget.

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October 27, UNMH Board of Trustees Meeting Minutes

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October 27, 2017 Barbara and Bill Richardson Pavilion 1500

UNM Hospital Board of Trustees Minutes October 27, 2017

1

Agenda Item Subject/Discussion Action/Responsible Person

Voting Members Present Jerry McDowell, Erik Lujan, Nick Estes, Christine Glidden, Joseph Alarid, Terry Horn, and Dr. Aimee Smidt

Ex-Officio Members Present

Dr. Paul Roth, Dr. Michael Richards, Dr. Michael Chicarelli, Dr. Jennifer Phillips, Ava Lovell, and Chaukoui Abdallah

County Officials Present Timothy Olivas

I. Call to Order A quorum being established, Mr. Jerry McDowell, Chair, called the meeting to order at 9:08 AM

II. Announcements Mr. Jerry McDowell, Chair, welcomed Ex-Officio Members, Ms. Ava Lovell and Mr. Chaukou Abdallah to the Board Meeting. Dr. Michael Chicarelli reported UNMH was recognized in the 2018 Edition of U.S. News & World Report “2017 Best Hospitals” for delivering evidence-based treatment guidelines to improve quality of care for heart disease and stroke patients (copy in packet). Dr. Jennifer Phillips presented a Chief of Staff Update (report in packet).

III. Adoption of Agenda Mr. Jerry McDowell, Chair, requested a modification to the Agenda – Move Chairman’s Report to first item under Board Initiatives. Mr. Jerry McDowell, Chair, requested a motion to adopt the agenda with the requested change.

Mr. Nick Estes made a motion to adopt the agenda with the identified modification. Mr. Joseph Alarid seconded the motion. Motion passed with no objections.

IV. Public Input Public Input was given by Ms. Siressa Manne, NM Center on Law and Poverty, and Ms. Michelle Melendez, Ele Valle, in reference to the Patient Payment Policy, the Financial Assistance Policy and on the 138 public comments received by Bernalillo County on the MOU.

V. Consent Approval

No Consent Items Presented.

VI. Approval of Minutes Mr. Jerry McDowell, Chair, requested a motion to approve the September 29, 2017 UNMH Board of Trustees Meeting Minutes.

Mr. Jerry McDowell, Chair, requested a motion to approve the October 3, 2017 Special UNMH Board of Trustee Meeting Minutes.

Mr. Nick Estes made a motion to approve the September 29, 2017 UNMH Board of Trustees Meeting Minutes. Mr. Terry Horn seconded motion. The motion passed unanimously. Ms. Christine Glidden made a motion to approve the October 3, 2017 Special UNMH Board of Trustees Meeting Minutes. Mr. Erik Lujan seconded motion. The motion passed unanimously.

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VII. Board Initiatives Mr. Jerry McDowell, Chair, reported the following:

o Action items from Board of Trustees Meetings will be tracked and listed in the following month’s agenda.

o In a future meeting, management will present thoughts on how they would like to proceed in reference to Larry Gage’s recommendations.

o Mr. McDowell recently met with Commissioner Hart-Stebbins and will set up a meeting with Interim President Abdallah.

o Mr. McDowell has been asked to Co-Chair the CEO Search – there have been two good orientation sessions held and they are in the process of gathering input with a decision expected in early 2018. There was a link at one of the orientation sessions with a wonderful video of the hospital, which would be beneficial for the Board of Trustees to review. Mr. McDowell thanked Dr. Mike Chicarelli for taking on the responsibilities in the Interim role as the search unfolds.

o Mr. McDowell is interested in seeing Mission Excellence proceed.

Dr. Michael Chicarelli and Mr. Scot Sauder explained the changes/modifications made to the Patient Payment Policy and Financial Assistance Policy and the new proposed Discount Program Policy. Mr. Nick Estes suggested a statement is included on the Discount Program Policy that would indicate a monthly amount would be set by the patient’s family income and size and be put on a schedule. Upon discussion, Mr. Jerry McDowell, Chair, entertained a motion to approve all three policies as presented with the understanding that Board Member, Nick Estes, has raised an issue which may be addressed at a future date as an amendment to the Discount Program Policy. The Board of Trustees requested to be updated on how the implementation of the policies proceeds.

Ms. Sara Frasch presented an update on Mission Excellence (report in packet). Mr. Jerry McDowell, Chair, requested a presentation by DYAD partners. Dr. Michael Richards will showcase DYAD Partners at the next Mission Excellence Leading to Excellence.

Mr. Joseph Alarid made a motion to approve the Patient

Payment Policy, Financial Assistance Policy and the

Discount Program Policy as entertained by Chair

McDowell. Dr. Aimee Smidt seconded motion. The

motion passed unanimously.

VIII. Administrative Reports

Chancellor for Health Sciences Report: Dr. Paul Roth reported that he recently met with

Legislative Committee. Dr. Roth stated the five UNM President candidates have been interviewed and the committee will meet next week to discuss interviews and make a decision. Announcement is expected to take place by November 5th. There is an active search for two of the three Dean candidates with the assistance of an outside search firm.

CEO Report: The CEO (report in the packet).

CMO Report: The CMO (report in the packet).

UNM Board of Regents Report: No report.

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IX. Updates N/A

X. Committee Reports Quality and Safety (formerly POCEC) Committee: The Quality and Safety Committee met

on October 20, 2017. Ms. Christine Glidden gave a brief summary.

Finance, Audit & Compliance Committee: The Finance, Audit & Compliance Committee met

on October 25, 2017. Mr. Erik Lujan gave a brief summary.

Native American Services Committee: The Native American Services Committee met on

October 25, 2017. Mr. Erik Lujan gave a brief summary.

Executive Committee: No report.

XI. Other Business September Financials: Dr. Michael Chicarelli gave an update on the September Financials. XII. Closed Session At 11:14 AM Mr. Jerry McDowell, Chair, requested a motion to close the Open Session of the

meeting.

Mr. Nick Estes made a motion to move to Close Session. Mr. Erik Lujan seconded the motion. The motion passed unanimously.

XIII. Certification After discussion and determination where appropriate, of limited personnel matters per Section 10-15-1.H (2); and discussion and determination, where appropriate of matters subject to the attorney-client privilege regarding pending or threatened litigation in which UNMH is or may become a participant, pursuant to Section 10-15-1.H (7); and discussion of matters involving strategic and long-range business plans or trade secrets of UNMH pursuant to Section 10-15-1.H (9), NMSA, the Board certified that no other items were discussed, nor were actions taken.

XIV. Vote to Re-Open Meeting

At 1:05 PM, Mr. Jerry McDowell, Chair, requested a motion be made to return the meeting to Open Session.

Mr. Jerry McDowell, Chair, requested a motion be made to approve the September 20, 2017 Medical Executive Committee (MEC) Meeting Minute as presented in the Closed Session to acknowledge, for the record, that those minutes were, in fact, presented to, reviewed, and accepted by the Board and for the Board to accept/approve the recommendations of those Committees as set forth in the minutes of those committees meetings and to ratify the actions taken in Closed Session.

Mr. Jerry McDowell, Chair, requested a motion be made to approve the September 22, 2017 Quality and Safety Committee Meeting Minutes as presented in Closed Session to acknowledge, for the record, that those minutes were, in fact, presented to, reviewed, and accepted by the Board and for the Board to accept/approve the recommendations of those Committees as set forth in the minutes of those committees meetings and to ratify the actions taken in Closed Session.

Ms. Christine Glidden made a motion to return to Open Session. Mr. Terry Horn seconded the motion. The motion passed unanimously.

Mr. Nick Estes made a motion to approve the Medical Executive Committee Meeting Minutes. Mr. Joseph Alarid seconded the motion. The motion passed unanimously.

Ms. Christine Glidden made a motion to approve the Quality and Safety Meeting Minutes. Mr. Terry Horn seconded the motion. The motion passed unanimously.

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Mr. Jerry McDowell, Chair, requested a motion be made to approve the Credentialing and the Clinical Privileges as presented in Closed Session:

Dr. Aimee Smidt made a motion to approve the Credentialing and Clinical Privileges as presented in Closed Session. Mr. Joseph Alarid. The motion passed unanimously.

XV. Adjournment The next scheduled Board of Trustees Meeting will take place on Friday, November 17, 2017 @ 9:00 AM at the University of New Mexico Hospitals in the Barbara & Bill Richardson Pavilion (BBRP) 1500. There being no further business, Mr. Jerry McDowell, Chair, requested a motion to adjourn the meeting.

Ms. Christine Glidden made a motion to adjourn the meeting. Mr. Joseph Alarid seconded the motion. The motion passed unanimously. The meeting was adjourned at 1:05 PM.

___________________________________________ Dr. Raymond Loretto, Secretary UNM Hospital Board of Trustees

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Board of Trustees MeetingFriday, November 17, 2017

1

Board Enhancement(Gage Recommendations)

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Recommendations for Consideration

• Reduce Board of Trustee Meetings to six per year (once every two months), with much of the work between meetings done in committees. With a reduced number of meetings, management should be able to provide Board materials at least one week in advance of each meeting.

• Implementation Strategy:

– Develop Board Committee structure and schedule

– Consider timing of Board meetings to coincide with critical operational timelines such as budget submission

– Consider length of Board meetings

– Revise Hospital and Board policies to reflect edits

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• UNMH and the BOT, in consultation with the Regents and County Commission, shall develop a process for identifying gaps in Trustee experience and identifying potential Trustee candidates.


– Stakeholders develop desired criteria for Board members based on professional experience, community experience and interpersonal style.

– Review with stakeholders annually


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• Three Board of Trustees on each Committee, with each Board of Trustee serving on a maximum of two Committees. Non-Trustees with requisite skills and experience should be included on Committees where appropriate.


– Review current Board Committee assignments

– Assess skill set of members as it relates to a specific committee and consider assignment/re-assignment


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• Reorganize Committee Structure, which would spread the workload more broadly and provide more opportunities for Board of Trustees to participate in Committee work (Budget and Finance , Audit and Compliance, Patient Care Quality and Safety, Strategic Planning and Community Engagement, Native American Services).


– Development of the committee structure to include members


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• If the frequency of Board of Trustee Meetings is reduced, delegate the Quality Committee to assume Credentialing and Privileging responsibilities between Board of Trustee Meetings.

• Implementation Strategy:– Review with OUC

– Required for a change in Full Board meeting schedule (every other month)


• Hold brief Executive Sessions at the end of each Board of Trustee Meeting (with or without presence of Ex-Officio Trustees), provided that such meetings are consistent with applicable Open Meeting requirements and major issues addressed in Executive Sessions are communicated by the Chair to CEO for follow-up purposes.

• Implementation Strategy:– Review with OUC


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• Provide increased opportunities for engaging Board of Trustees in major UNMH initiatives such as educating members about important health industry developments, including developments affecting quality and financial performance.

• Implementation Strategy:– Review with OUC– Revise Hospital and Board policies to reflect edits

• Develop mechanisms for communicating effectively with Board of Trustees between meetings (retreats, social events and educational sessions).

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• UNMH undertaking a strategic planning process to identify the challenges and goals unique to UNMH within the overall context of UNM and UNM Health Sciences.

• Expand the use of Board of Trustee self-evaluation mechanisms.

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Recommendations Held in Abeyance

• Reduce the current number of Ex-Officio Trustees– Requires By-Law Amendment

• Increase voting Board of Trustees Members by three.– Requires Lease Amendment

• If voting Board Members is increased by three, have the Hospital CEO become an Ex-Officio voting member of the Board– Requires Lease Amendment

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Patient Payment Policy

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Policy Implementation Update

UNM Hospitals Board of Trustees

October 27, 2017

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New Policy Documents

• Approved by UNM Board of Trustees 10/27/17

– Financial Assistance Policy

– Patient Payment Policy

– Discount Program Policy ( New)

2

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Internal Roll Out Plan

3

Front Line Education to put new policies on-line. Kris Sanchez Sandra Mora

Present at Supervisor Forum on 11/14/17. Kris Sanchez Sandra Mora

Create a Quick reference Guide (QRG) for explaining policies. Kris Sanchez Sandra Mora

Determine who needs to be educated. Kris Sanchez Sandra Mora

Update FRONTLINE Manual. Kris Sanchez Sandra Mora

Task Leads

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Internal Roll Out Plan`

4

Update scripting for frontline staff around co-pay and down-payment obligations.

Kris Sanchez Sandra Mora

Three Financial Services documents need to be updated. Molly Chavez

Create a sign-in log for training all PSRs, PCCs and Financial Counselors Molly Chavez

Send BHO PCCs to training JoAnne Loporto

Get the revised polies to the Financial Counselors and explain changes. Raquel Bennett Christi Davies

Present new policies at Financial Counselor forum. Raquel Bennett Christi Davies

Task Lead

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Have Financial Counselors contact any patients they have worked with, but have not already had the procedure performed and update the patient according to the revised policy.

Raquel Bennett Christi Davies

Present new policies at PCC forum. Raquel Bennett Christi Davies

Create binder with copies of all Policy documents, sign-off sheets, QRGs, and training materials.

Craig Klappauf

Update management in Surgery and Admitting about the three policies.

Sherry Pinkston Raquel Bennett

Create a summary of changes document for presenting to all staff. Rodney McNease

Task Leads

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Need to clarify with UNMMG and SRMC how they relate to these new policies

Rodney McNease

Clarify with SRMC that this is effective if there is a UH referral or a UH Capacity problem.

Rodney McNease

6

Task Leads

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External Outreach Plan

• Update all Public documents and Website with

updated policy information

• Send new policies to community list serves and

community navigators such as pathways

• Outreach to community navigators on in person

training around new policies

• Update Community Partners such as First

Choice, First Nations, Healthcare for the

Homeless etc.

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Questions?

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Mission Excellence Update

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Mission: Excellence Update

• In alignment with the Execution Framework for Studer Group’s Evidence Based Leadership, current activity continues to focus on aligning goals across the Health System entities. Leadership goals have been entered into the Leader Evaluation Manager. Leaders were trained and asked to review their goals, validate the target metrics and assign a weight to total 100% (performance). We have started to enter the first quarter metrics into the system, and are planning a goal equity session the first week of December. The Accountability team has been meeting with School of Medicine Department chairs to ensure alignment of goals, and advise on cascading goals to Vice Chair and Medical Directors.

• The Clinical Leadership Dyad Education (CLDE) launched on October 31. Medical Director and Unit Directors from three clinical areas (six participants) provided feedback during a pilot session to refine content and process for this training program. Three of the five modules have been developed, with December 13 providing an opportunity for dyads to attend three of the five module linkage labs. CLDE content and requirements will be populated on all dyad learning plans the first week of December, so that dyad partners know they have this resource available.

• The Communication Team is now providing ALL staff with updates via email newsletter. This newsletter focuses on how our team members are exemplifying the new Behaviors of Excellence, contests, recognitions, and other engagement updates.

• Planning for the December LEADing to Excellence session is ongoing, with a draft agenda receiving approval from Health System leadership on November 13. Content will focus on improving our performance by learning about high and low performing organizations, reviewing our employee and physician engagement scores, training our leaders on how to communicate and action plan around results and improve retention.

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CEO Report

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MEMORANDUM To: Board of Trustees From: Michael Chicarelli Interim Chief Executive Officer Date: November 17th, 2017 Subject: Monthly Activity Update The Hospital has been involved in a variety of activities and this report will focus on services delivered through October 2017. Quality: Due to the timing of the Board meeting, the quality indicators for October are not available. Management will present the October results in the December meeting. Statistics: UNMH finances through October 2017 have not been released at this time and close is expected to take place early next week. Financial: UNMH finances through October 2017 have not been released at this time and close is expected to take place early next week. Strategic Planning: Planning continues related to the replacement hospital design that has been approved by the Regents. The request for proposals (RFP) was initiated on 9/29/2017 and will close today. Following the close of the RFP a multi-stakeholder team will score the bids and name an awardee. Once awarded, planning is expected to begin within a month with a total time line of 15-18 months. Management will continue to update the Board as progress continues. Human Resources: The turnover rates are now around 16% for the full workforce and 15.5% for nurses as a subset, about the same for the past year. UNMH has 5920 employee which is 321 less FTE’s than the budgeted FTE allocation. The total FTE count for nurses is 1869 which is 79 less than the FY 18 budget. Native American Liaison: The Native American Liaison Committee continues to review compliance with the condition of the 1952 Contract, the Lease and the two Consents to amend the Lease. Work continues on the review of the Hospital compliance with the 100 bed provision of the Contract. We have provided a legal opinion about UNM’s interpretation of the provision and are waiting for an opportunity to engage in a dialogue on the matter. On November 10th, the HSC hosted the All Pueblo Council of Governors, State and IHS officials at the UNM Cancer Center. The event had a noteworthy attendance and management had an opportunity to discuss hospital performance, UNM Cancer Center innovation and respond to questions from the attendees. Bernalillo County: Management continues to interact with the County, Indian Health Service and the Board of Trustees on the Memorandum of Understanding (MOU). At this time there is no new information to share with the Board. I will continue to update the Board as progress occurs. If there are any questions on this or other matters, please feel free to contact me.

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CMO Report

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To: Board of Trustees From: Irene Agostini, MD UNMH Chief Medical Officer Date: November 17, 2017 Subject: Monthly Medical Staff and Hospital Activity Update 1. The average wait time for a patient from the Adult Emergency Department to be placed after admission for the month of October was 12 hours. In October of 2016 the placement time was 5 hours and 48 minutes UNMH Remains greater than 90% capacity.

We sent 33 patients to an SRMC Inpatient unit instead of placing at UNM Hospital. 2. The Community Partnership with Lovelace Health system continues to be successful in putting the needs of the “Patient First”, allowing continued access to those patients that can only be cared for by UNMH. In the month of November:

72 patients were triaged from the UNM Health System to Lovelace inpatient units. 3. Our ALOS (average length of stay) for October 2017 was 7.22 as compared to October 2016 which was 6.35. We continue to hardwire our new processes to decrease our ALOS despite accepting higher acuity patients. 4. Our “LEADing to Excellence” quarterly retreat will occur on December 14, 2017 to close out the year.

The Key Takeaways to Hardwiring Excellence will include the following:

Quality and Safety as our number one priority

Cascading goal alignment

Behavioral expectations for all

Dyad partnerships

We are in this together, removing the “us” vs. “them” mentality

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Native American Services Committee

Separator Page

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UNM HOSPITAL BOARD OF TRUSTEES

NATIVE AMERICAN LIAISON COMMITTEE

Date October 25, 2017 Time 1:00 PM Location CEO Conference Room, UNM Hospital Administration

Meeting Attendees Christine Glidden, Rodney McNease, Erik Lujan, Misty Salaz, Kori Beech, Scot Sauder, Michael Chicarelli,

Minutes Agenda # /Subject Status / Discussion

Action / Next Step Responsible Party

I. Call To Order – I. Ms. Glidden brought the meeting to order

II.

Approval of Agenda- Motion made by Ms. Glidden

Approved

III. Approval of Minutes – Motion made by Ms. Glidden Approved

IV. Public Comment- There was no Public Comment

V. Mr. Sauder gave an update on the status of the 100 bed language. Currently Indian Health Service is reviewing the proposed language and UNMH is awaiting their feedback in order to finalize.

Scot Sauder, Pablo Padilla

VI. Discussion of 100% FMAP status. UNMH has worked with IHS, and the Human Service Department related to implementation of the required care coordination agreement. UNMH is completing the necessary operational steps to move forward with implementation in December 2017. UNMH has provided a legal opinion to HSD in order for them to review and submit to CMS related to considering UNMH as an IHS like facility.

Accepted as information

VII. Discussion of Tribal Consultation meeting and agenda. The Tribal Consultation has been moved back to November 10th. The committee reviewed the final proposed agenda.

Kristina Sanchez, Misty Salaz

VIII. Bernalillo County Update- Brief discussion of the status of the proposed MOU with Bernalillo County and that the County has provided additional information to UNMH and IHS for consideration based on public comment received on the document. .


IX. New Business- There was no new business


X. Adjournment – Meeting was adjourned

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UNM Hospital Board of Trustees OPEN SESSION AMENDED AGENDA ... · 11/17/2017 · UNM Hospital Board...

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