HomeMy WebLinkAbout20154109.tiff NCMC BOARD OF TRUSTEES
Regular Session Meeting
Tuesday, January 13, 2015
Attachment 1
Minutes of Regular Session of
December 15, 2014 *
* - Action Required
NCMC Board of Trustees
Regular Session Minutes
Monday, December 15, 2014
12:00 Noon
The Board of Trustees of North Colorado Medical Center met in Regular Session on Monday,
December 15, 2014, in the Richard Stenner Boardroom located at North Colorado Medical
Center. Mr. Houtchens declared a quorum and called the meeting to order at 12:00 p.m.
ATTENDANCE REPORT
NCMC Board of Trustees: Dr. Susan Carter, Thomas Grant, Brandon Houtchens, Mark
Lawley, Dave Owen, Michael Simone, Jason Yeater, and Sean Conway (Commissioner,
non-voting member), with Dave
Banner Health: Rick Sutton (NCMC CEO) and Wendy Sparks (NCMC COO)
Staff: Ken Schultz (Board Executive)
Recording Clerk: Esther Gesick (Weld County Clerk to the Board)
PUBLIC COMMENT
There was no public comment.
APPROVAL OF MINUTES
It was MSC (Carter/Simone) to approve the minutes from the November 24, 2014, Regular
Session meeting.
NEW BUSINESS
There was no new business.
VISITATION REPORTS
ENDOSCOPY DEPARTMENT
Jason Yeater reviewed his report, dated December 15, 2014. A written copy of the
visitation report is attached as a part of these minutes. There was discussion concerning
the various processes and procedures.
RISK MANAGEMENT
Brandon Houtchens reviewed his report, dated December 11, 2014. A written copy of the
visitation report and an associated handout are attached as a part of these minutes. There
was discussion concerning the best approach when there is an incident.
CEO REPORT or COO REPORT
NCMC COO, Wendy Sparks, gave the following report:
• Today is the last day for employees to receive flu shots or be placed on administrative
leave for one week.
. Leaders are attending "Just Culture"training in the event of an incident.
Page 1 of 2 December 15,2014 NCMC Board of Trustees
• Patient Satisfaction -the facility is meeting target/stretch on all seven dimensions.
• Quality - hitting eight of ten Quality Strategic Initiatives.
• Physician recruiting is ongoing.
• Financials - for the month of November the Greeley Community had an operating gain
of$1.6 million, and Year-to-Date it is ahead of budget by $4.9 million. The NOCO area
had an operating gain of$612,000 for the month and Year-to-Date it is ahead of budget
for $4 million.
• Master Campus - projects are on track, the magnet for the new MRI has been placed
and they will start scheduling patients for the week of January 19th. The large tower
crane and the temporary boiler will both be removed the first week of January.
VISITATIONS FOR FEBRUARY
Dr. Susan Carter
Mark Lawley
NCMC, INc. REPORT
Brandon indicated there is nothing new to report.
COMMISSIONER'S REPORT
Commissioner Conway introduced the new County Attorney, Robert Frick, effective
December 1, 2014, and Bob said it is good to be back with Team Weld County.
Commissioner Conway reported the 2015 Final Budget has been approved, with the mill
levy reduced to 15.8 mills. He commented the lowered oil and gas prices do not impact the
current budget since the production schedule is one year behind and will not be reflected
until 2017. He stated the Board has had discussions with the larger producers and their
intensions for 2015 remain consistent, although they are monitoring the situation closely.
He referenced the Greeley Tribune article regarding Weld County's Retirement funding and
explained it is fully funded and compliant, and the County has no sales tax and remains
without debt. He confirmed he will be reappointed to the Trustee Board as the
Commissioner Representative for 2015.
OTHER BUSINESS
There was no other business to discuss.
PLANNING SESSION
No discussion was held on scheduling a future planning session.
ADJOURN
There being no further business to come before the Board, it was MSC [Lawley/Simone] to
adjourn the meeting at 1:05 p.m.
Respectfully submitted,
Esther Gesick
Page 2 of 2 December 15,2014 NCMC Board of Trustees
NCMC Board of Trustees Report
Jason Yeater 12/15/14
Endoscopy Department
Department History:The Endoscopy Department was recently built in 2009, and has remained in its
current location.The 2009 project was a design build with heavy influence coming from the Endoscopy
staff. Because the area was specifically built for the Endoscopy department,the staff is able to conduct
on average, 20 procedures per day while only utilizing 40%of the facilities capacity.At times,the
demand for services increases, and more procedure rooms are utilized with the aid of float staff. In an
effort to maximize the space,the pre and post procedure area is currently being used by the Oncology
Department for outpatient infusion which sees approximately 20 patients per day.
Services_The Endoscopy floor provides a variety of specialized procedures. Each procedure takes on
average 45 minutes to an hour to conduct, however, procedures can vary greatly in length based on
both patient and doctor needs.The procedures can vary in time anywhere from 20 minutes to 6 hours.
The procedures themselves can vary as well, from an EGD (esophagogastroduodenoscopy),where a
scope is inserted into the esophagus (food pipe)to the stomach and duodenum (small intestine);to a
Bronchoscopy in which an endoscope is inserted into the trachea (air pipe) and the mainstem bronchi
(lungs) are examined. Other services provided include: a Colonoscopy,which examines the large bowel
and distal part of the small bowel; ERCP (Endoscopic retrograde cholangiopancreatography), a
procedure that combines gastrointestinal endoscopy and x-rays to treat problems of the bile and
pancreatic ducts; EL'S (Endoscopic ultrasonography),which allows for the examination of the
esophageal and stomach linings as well as the walls of your upper and lower gastrointestinal tract; and
lastly nurse mobility tests,which test for GERD and hernias.
Staff:The Endoscopy Department is staffed by five RNs,four endo surgical techs, and one health unit
coordinator. All staff scheduling is performed using a "staffing by demand model".Any additional
staffing needs are achieved with PRN staff. Procedures are performed primarily by three
Gastroenterology(GI) doctors. One point to note is that three GI doctors have left the community in the
past year.This has created a large demand on the remaining GI doctors.
Successes:The staff of the endoscopy department has been working together for numerous years.This
has created an environment that is highly professional, competent,and positive. All staff, including
physicians, are extremely hard working and are willing to put in the extra work as the department
grows. Dr. McWilliams in particular, has been a great addition to the department and has an "incredible
beside manor."
Another paint of pride for the department is its ability to perform Intravenous Endoscopy Procedures
which are not done at other local facilities, as well as the ability to handle a more complicated patient
with a difficult anatomy.Just one example of this is the department's ability to remove blockages from
patients with small bile ducts.
Over all,the Endoscopy department's biggest opportunity for success might be the environment in
which it operates.The recent departure of local GI doctors and the Endoscopy department's ability to
perform more complicated procedures, leads the department to believe there is a big opportunity for
growth.
Challenges:The greatest challenge in the short run for the department is staffing. Although highly
competent, current staff is being stretched to its limits at times. Management will soon be working with
a Labor Engineer, and believes that along with suggestions for optimization,staffing will be increased.
Combined with additional staff and the increase in market share,the Endoscopy department feels it will
soon be able to utilize two additional exam rooms.The short run goal of the Endoscopy department is to
add an additional 15 procedures per week.
Department Needs/Requests:Although the staff is very fortunate to be approved for seven new Endo
Scopes,a Mobility system,and a CO2 unit, they would like to have a dedicated fixed fluoroscopy unit(x-
rays) as well as a GIQUIC program (GI Quality Improvement Consortium).They feel that the addition of
these two items will allow them to increase the procedures, while at the same time having the ability to
track procedural quality.
What the department would like NCMC Inc.to know:That they have a great staff from the ground up.
They have a great facility and appreciate the support with all of the requests and needs that have been
submitted.
NCMC
RISK MANAGEMENT
Report to the NCMC Trustee Board
Visit by Brandon Houtchens, December 11, 2014
I met with Gloria Ybarra,MPH, BSN, RN, CPHRM. She is the Director of Risk Management. Her
department includes a staff of 3 people. The information attached to this report will describe in
better detail the responsibilities and functions of the department. The NCMC Risk Management
group is Team B,with responsibilities over NCMC, the West ED, Banner Paramedic Service,
Northern Colorado Family Residency, Est Morgan County Hospital, and BMG,
Overview: The department is responsible for communicating risk-management policies and
communicating with employees to address actual or perceived incidents of loss, damage, etc.,with
the goal of minimizing losses and preventing or mitigating claims when losses occur. The
department also assists when claims are brought, subpoenas issued, etc. The department does not
handle employment claims or collections.
Department History: Founded 1978; Merged with the Business Health Department in 1998.
Recent Changes: Changes are pending regarding the NoCo region. Team composition and
leadership is uncertain in the near future.
Services Provided: Emergency Management, HIPAA,Litigation Management, Records Retention,
Property Damage and Insurance, Professional/General Liability Claims,Workers Compensation,
Loss Prevention/Education, Risk Financing, Safety& Security, Patient Complaints and Grievances,
Theft and Vehicle Insurance,Litigation Management, Insurance Funding.
NCMC is predominantly self-insured, so claims are handled in-house. Malpractice claims are
handled by one of three Denver-based defense firms,who have handled NCMC claims for many
years,
Successes: Measuring the success of this department is difficult. Strategies implemented by Risk
Management might be designed to reduce the number of claims, suits filed, amounts paid in
settlement,verdicts, etc., but the lag between incidents and the outcome (i,e., statute of limitations
plus duration of litigation) makes it difficult to draw a causal link between the strategies and dollars
spent in response to incidents. Also, a. goal of the department is to encourage employees to report
incidents that might lead to claims, so success in this regard might lead to the reporting of more
incidents, which might (misleadingly) suggest that strategies designed to minimize incidents are not
succeeding.
Future: TBD regarding structure. Otherwise, I didn't learn of any imminent changes regarding the
function of the department.
Note: The Risk Management department facilitates payment to patients who have suffered some
adverse outcome (even when not the result of negligent care; even when the patient is advised that
the adverse outcome is a risk of the care) to help patients cope with the financial burden of longer
stays, missing work, etc.
1
a iLL - +j, a a I
y `ei 3 a 5 ' c a
:c too = o a g in O c = ao
,4 jL�1 Ey i, 73 C Ld fu Gi C 'G [�fa�¢7� I co Y
�' Q) cn a Z '!G ti 9 C N N _q v- O eta a
z _c @ f0 V a) a c U O = 6 V- c '� N vl I - t
UDUUVI }1 I ! 1
Q 9.
PN ro c co a
cc :ID Loll o 3 o r}a a a Q ° v o ��g a s
a to o a, E o e `' a u N
to oa 'o m al a c - w . , 3 a t° a3, a `v
Q' " — a +a JC ICI �r -0 E '_ , 0 v v c
° `� m ,� m "' rci a 8 a' t V
fo y a SO CU O t 43 G C � i ►� L +�.,
C °�.' 3 > " a o� u C7 3 '° 'm 1° _ c` aUi co 'al O 4 0
m - - V c o -a .c a l t "U E `m 'E 3 v, o o a
ty C a C — O cc-i E,E C i°� '41 .E p L' Z7 ta T tap 5 r m
3 ro } ++ a G -0 N O C a Y. hA 4-4 F- 7 Mme, C 10 F V
L
-„ a m as 3 3 m C v ' E O -0 tnn M —
o ro o v Lo a n s r43 LI c a 'x G s '14 x o qy o rco. o s •
U 5 4- CC 47 I— -A +.. CL Y 2 ar a =a ,.) a L L. CL of,t� +.,
i
0- I . I
LLII 'ppertri
411. v
a.
I
W ri N i CA
Iii
43.1
is
�
i
b _ ___
5 L O
To
Q 6.0
m
O OIV
CC le
LeC
a > oc
CO
�`F V LVI
V • Q 0.
VI
fr• C1. vi
C
4. U i UVI
4 di
C L C _ a
�y 41
QCO m N t_
O a a w a S S <
cnd °�
C a] '
o
ea � Z 0. a . xL 4 l a
c
0
cc rc T a) -0 a) c I v a a. CO t- a c
z �' 'V c ° `� `° v v v o °' o a1 v y
} m a� — v = a E 3 _ o u c a o = o c
I❑ U a •E a 3 3 co ra `- C O to `J J--� -� O ..... _c 7�
VI o ra 6. a a)
CI- bp m i I.-L, LIL O C — C 'a-' O o_ ,..: •"' O 4o rroo c a) a c
a m
❑ c Ip c a o ° E Ia) rt, v ° •c u c 3 ar v o_ a) --ca o
3 g u " a] c' E a O x I E ra -C - a+ +J 'o v, Q ro s
C C M 1 m ra a a-- C I m I]6 . C a I a U O a rn C L m >` no
m c .,--i c co a) U +m-• v >`Lel4} a c U V a U Y O a 7 Y Q Q O _0 L
#1 O cu 40 m •u E •° El .vl a Ham l '"' o 7 m Q 17 w CU L O o > o
E 3 .� Y m u ° a c .a1 v cc a u +.' ,} E
C 13 v x O av) = V E a co O'f-a a D _aI o i O m c
a7 I C Y P O a _
O CL, a Lr, m O w °C ,.. C a a 0- ° _ M .E — a a)
.vz u 4- ' Oro E 3 a 0 a E 71 as v -o -I - = m +- , 3 m 3 0 .c -0 Ln -C =
= C X .C ti a) in 1- v, ° a �io +' a C O O U Q) m 4.0 L 0 w a ri E +, C
▪ ` I L > o v Up
Sc o u `�° a o c ~ I a c 'r� m O 0 C C v
n 3 ° CD +� a n° u C ''O E i '''' 6- oo _c °c° q) L v °' C° a
a v o m a O v Y ca m C C 1= a ra 0 _C , v L 0
u LL a c I a a 7 O r0 a) rp
v CO .0 m '- .0 ❑ v) E p o • , a c ,, u y'r o 3 a oo c z o 3 c "' o oc u
w C. E 0 c — 3 s f° 3 m co a '.,1 .C
o a 0 LIIC c
O raa °, c., 0- Q., = ,22 JM m o a �: 'o al co •,c c c a m p u a ea c
cc L m a — tC u C 7 I I m a �;' _C *' C U L o
m V- a)i ra c o m 0 c o o I m l ro n ry I c -c v; "` _C a
C 0 0 c I u .0 ❑ - y i- un � -. .0 a L u E a. u '� ,� �. c •a .y a� v °0 c m o
0 o v v I b = d rn o !� a m 0 0 0 °-. c L o o l m c 3 m o awi o m r a nn w-
u U a? v, 3 ` >= 0 aoa o -I n +. V'I o a a u i 0 0 E a V1 ii a ° .C E
,
c l c � 3 a 0 3 I c Lo a)I c o a l c a 3 o -o l c o f °; cc a E a•1 v, t .
o m O Li U m c a Ill Ln O` c ,Ice r.° 0IL) m rroo;U u ° Q %,Cc) m Oy u rr O CO 1rms C
i i— --1--r - - --1
I I
I
l` � [�al I2 III
.....1-
I I
I I I
- - 1.- — .1
o i I i
Y
I ILri 1 0 I Q -0 Ln
C
I� rq I� ,N 7
L
c
I� I IQ r m c .Oa
c o
m
I I I
vi
o I o
;� L
` = c a
Q IL
NO VI O
I '2iil
I Y I u I C
S ` '^
I
a +`r C ro m
c a loo a
a
�,
a I U a I C >
C I
v I a E I ❑
C �, C 1C) E Ia
= J Iz w
C a
- I — -
C
' C o
, a)
I E
II a 4
O
I4 IV 0 E D ~
I_ 71 It mC taro m
CtC [a a -- o- a °o
IJ 'C U W U cc W 1r7� 2'
Hello