HomeMy WebLinkAbout20154118.tiff NCMC BOARD OF TRUSTEES
Regular Session Meeting
Monday, October 26, 2015
Attachment 1
Minutes of Regular Session of
September 28, 2015 *
* - Action Required
NCMC Board of Trustees
Regular Session Minutes
Monday, September 28, 2015
12:00 Noon
The Board of Trustees of North Colorado Medical Center met in Regular Session on Monday,
September 28, 2015, 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, Catherine Davis, Brandon Houtchens, Mark
Lawley, Michael Simone, Brian Underwood, and Jason Yeater, with Sean Conway
(Commissioner, non-voting member) being excused
Banner Health: Rick Sutton (NCMC CEO), with Wendy Sparks (NCMC COO) - Excused
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/Davis)to approve the minutes from the August 31, 2015, Regular Session
meeting.
NEW BUSINESS
None.
CEO REPORT or COO REPORT
NCMC CEO, Rick Sutton, gave the following report:
• Employees - The Joint Commission arrived on September 5th, with five surveyors who
spent four days conducting a facility audit. Based on their findings, 45-day and 60-day
action plans were drafted to correct any deficiencies. As a result, NCMC is now fully
accredited for another three years.
• Patient Satisfaction - During August, NCMC hit target on four of the eight dimensions,
with continued emphasis on going back to the basics and reenergized student principles.
The September scores are coming in, along with 60 surveys reflecting high scores, so he
is confident they will get back on track within the year.
• Quality- NCMC is hitting Stretch on all of the Care Reliability for Total Joint Care and Heart
Failure initiatives.
• Physicians - Physician recruitment is ongoing for several specialty areas, primarily in the
area of OBGYN staff to relieve the call burden. The OBGYN clinic has moved out to the
newly finished area in the Summit View 3rd Floor.
Page 1 of 2 September 28,2015 NCMC Board of Trustees
• Financials - In August there was an operating gain $863,000 for the Greeley Community,
for a total of $11.7 million Year-to-Date. NOCO was ahead $274,000 for the month of
August and is $7.4 million above budget for the year.
• Master Campus Plan - The crane will remain for about a year to redo the exterior of the
C building, including replacement of the AC/HVAC unit.
There was additional discussion concerning the national conversion from ICD9 to ICD10,
which is significantly more detailed on coding and must be enacted by October 1, 2015.
VISITATION REPORTS
NCMC EMERGENCY DEPARTMENT
Brian Underwood reviewed his report, dated September 16, 2015. A written copy of the
visitation report is attached as a part of these minutes. There was discussion concerning the
percentage of overall hospital population that generates from the Emergency Department,
which averages 50,000 patients per year. Rick also discussed the admissions contributions
from the satellite Emergency sites.
INFECTION CONTROL DEPARTMENT
Catherine Davis reviewed her report, dated September 27, 2015. A written copy of the
visitation report is attached as a part of these minutes. There was discussion concerning the
upcoming flu season and informing the public of their immunization options and good
hygiene practices.
VISITATIONS FOR OCTOBER
Dr. Susan Carter
Michael Simone
NCMC, INc. REPORT
Ken stated next month he will be giving a report on the insurance review that is required
under the lease; however, he is currently waiting on some clarification from Banner before
finalizing the report.
COMMISSIONER'S REPORT
Commissioner Conway was excused.
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 [Simone/Lawley] to
adjourn the meeting at 12:43 p.m.
Respectfully submitted,
Esther Gesick
Page 2 of 2 September 28,2015 NCMC Board of Trustees
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Department: NCMC Emergency Department
Report to the NCMC Trustee Board
Visit by Brian Underwood, September 16, 2015
I met with Jesse De Waard, Director of Emergency Services for Banner hospitals in Greeley, Loveland and
Ft. Collins, and Todd Arnold, NCMC Emergency Director. Jesse is a rather new employee to Banner
Health. He stated that he chose Banner because Banner's national reputation as a leader in health care
ranks right up there with Mayo and The Cleveland Clinic; Banner is recognized for setting industry
standards (Colorado is a nice place to live as well).
I began my interview by informing these gentlemen that I live in the local community and, as a Trustee,
want to be able to help communicate the reason(s) why a patient should choose Banner/NCMC over
other competing services when they have emergency medical needs. The public is concerned about
wait times, cost and quality. Here's what I learned:
Free-Standing ER:
Colorado and Texas are the only two States that allow free-standing ERs; emergency care services
provided outside of the hospital. In Greeley, Banner Health operates a free-standing ER near 71st Ave
and 20th St in addition to the Emergency Department at NCMC. Patients requiring emergency care can
go to either location. If the patient requires additional services not available through the free-standing
facility, an ambulance will transfer the patient to NCMC. The point here is that the patient's emergent
medical condition will be appropriately provided through either facility. Since Banner Health - NCMC
also runs an Urgent Care facility near this location and because UC services are typically provided at less
cost, I asked whether a patient would be advised to use the UC rather than the ER when appropriate. I
was informed that this can happen prior to admitting the patient to the ER however EMTALA regulations
can make this difficult. The interaction between the UC and Free-standing ER is an area of active
discussion.
Operations:
NCMC has a 50 bed emergency department (an appropriately sized ED for this size of hospital; similar to
MCR and Longmont). It is a Level 2 Trauma Center and is able to handle the vast majority of all patient
emergency medical and trauma needs. The department boasts exceptional care in all major areas:
cardiology(see recent Tribune article), stroke (including tele-health services with Denver Swedish) and
trauma care. The ED is also a behavioral health/mental health "safety net" staffed with a special team
(including licensed social workers) to effectively treat and/or manage mental health needs.
ED leadership is focused on having an engaged workforce, providing an excellent patient experience,
and achieving quality outcomes/results. I sought to quantify these objectives and was told the
following: Patient visit patterns of this 24 X 7 operation effect staffing. The door-to-doc time of ED visits
averages about 16 minutes(the goal is to be under 20 minutes; national ED requirements are 30
minutes). The department is hitting its stretch target in patient satisfaction scores (requires that 78%of
patients are seen in a "timely" manner).
The use of electronic medical records is helpful to the ED docs when treating patients; it is also a great
tool forgetting information back to a patient's primary care physician. Patients are also able to access
information on the EMR. Note that any physician (whether formally aligned with Banner or not) is able
to access electronic data on their patient.
ED physician services at NCMC are contracted through Team Health; a national provider of ED physician
services. Banner also uses Team Health for physician ED staffing at its Ft Collins and Sterling medical
centers as well as several Banner hospitals in Arizona. Banner is very pleased with the services received
through Team Health. The docs are engaged in helping Banner/NCMCC meet it's service objectives; they
are also instrumental in maintaining good interaction with PCPs.
Final note, Mr De Waard stated that the competitive interaction with pre-hospital providers is typical of
any major medical center that operates in a competitive environment. He also stated that NCMC
sponsors an annual Trauma Conference that seeks to educate and promote strong working relationships
between pre-hospital providers, rural physicians, PCPs, and specialists. This year's conference will be
held at the Embassy Suites on October 16th.
Respectfully submitted,
Brian Underwood, NCMC Board of Trustees
rP140.01tel 49121/2016,
NCMC - Infection Control Department Review September 27, 2015
Catherine C. Davis, Ph.D.
Summary: The Infection Prevention Team has three staff members and
collaborates with the Infectious Disease physician (NCMC) over 3 different facilities
(NCMC, McKee, Banner-Ft. Collins). They ensure that construction activities at
NCMC do not contribute to increase infection rates within the hospitals, collaborate
with the Central Processing Department for appropriate management of reusable
equipment, complete mandated hospital infection surveillance and reporting.
Recent Joint Commission visit found 1 major and one minor issue that were
corrected immediately. * The universal number - 8102143 - will connect a Banner
employee to an Infection Preventionist who answers the Western Regional pager.
Background
Management Team: Janet S. Conner, MPH, MT (ASCP), CIC* (27 years)
Joslin Minet, BSN, (2 years)
Ashely Weir, MPH, CIC (4 years)
*Met with this person
History of Contacts:
Janet is a Medical Technologist and received her MPH degree from Walden
University completing a capstone project regarding education of wrestlers in high
school about MRSA. Ashley holds a BS in Microbiology and MPH from CSU. She is a
CIC and has worked for Banner for 4 years. Joslin started out as a CNA with Banner
and recently received her BSN. She has been employed in the department for 2
years and is will sit for her CIC exam soon. The three rotate through the various
facilities and are available by pager. The industry standard is 1 FTE for 100
occupied beds.
Services Provided:
1. Survey Hospital Construction Sites daily especially as related to air handling
2. Barriers/Precautions as needed for inpatients. (Education for PPE for Ebola
cases)
3. Surveillance on a daily basis
4. Communicable Disease reporting
5. Central Processing - (linked in with organization°
6. Hospital Education - Influenza vaccinations inpatient and employees as well as
new employee education
7. Round Everyday
There is videoconferencing for all facilities that involves physician participation and
data presented on share point. Discuss variety of reportable infections from C.
difficile to surgical related infections.
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Working with Colorado School of Public Health to develop a rotation at NCMC for
MPH students who wish to gain experience with Hospital Infections Prevention
projects.
Successes:
Hand hygiene (no alcohol sanitizer for C. dtfficile patients)
Reduction of central line infections- scrub the hub
Reduction of"CATI" - get Foley catheters out as soon as possible
Use of Microfiber charge clothes to reduce bioburden before sanitizing surfaces
And 10% bleach solution where possible. ATP tests to monitor environmental
bioburden.
Reduction of superficial post-surgical C-section infections
Challenges/Obstacles:
Developing network of CIC actively working in the area.
Need press releases of Banner Health success in preventing infections and tips on
what to do with preventing infections (such as influenza)
Departmental Needs/Requests: Thank them for supporting the program.
Investigate if it is possible to start a monthly collaboration between acute and LTC
facilities in the region for discussions about best practices. Costs would be an hour
of the employee's time for meeting, lunch for attendees, and meeting room. Propose
to prevent infections appropriately in order to reduce infections in all facilities. This
would include the Director of Nursing, CICs and the goal would be to help each
other.
What Would The Department Manager/Director Like NCMC Trustees To
Know: "I am proud to work here. This facility, Banner Health and NCMC, has
treated me very well. This is a high-performing organization. We have an excellent
working relationship with the ID physician, Dr. John Breen. If any questions or
concerns develop, the universal pager number is 8102143 and a person carrying the
pager will answer. Also don't hesitate to knock on our door. We have moved a lot
but are currently on the 2nd Floor."
• Major: High-level disinfection and storage endoscope cannot be looped on
itself. Addressed by forming "S" shape using hooks for hanging.
• Minor: Lot# of test disks not recorded to confirm chemical sterilization.
Addressed by updating the form and documenting the information.
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