HomeMy WebLinkAbout20144028.tiff NCMC Board of Trustees
Regular Session Minutes
Monday, April 28, 2014
12:00 noon
The Board of Trustees of North Colorado Medical Center met in Regular Session on Monday,
April 28, 2014, in the Richard Stenner Boardroom located at North Colorado Medical
Center. Mr. Houtchens declared a quorum and called it to order at 12:10 p.m.
ATTENDANCE REPORT
NCMC Board of Trustees: Dr. Susan Carter, Thomas Grant, Brandon Houtchens, Dave Owen
and Michael Simone
Banner Health: Rick Sutton (NCMC CEO) & Wendy Sparks (NCMC COO)
Staff: Ken Schultz (Board Executive) & Rhonda Savoy (Recording Secretary)
Guests: Sean Conway (Weld County Commissioner) & Esther Gesick (Weld County
Administrative Assistant)
PUBLIC COMMENT
There was no public comment.
APPROVAL OF MINUTES
It was MSC (Owen/Grant) to approve the minutes from the January 14, 2014 Regular
Session meeting.
It was MSC (Owen/Grant) to approve the minutes from the January 14, 2014 Annual
Session meeting.
INTRODUCTION OF NEW MEMBERS
Brandon Houtchens announced that the County Commissioners have selected two new
members to the Board. He introduced Mike Simone, a chiropractor, who informed the
Board that he served as mayor of Firestone from 2006- 2008 and is now the president of
the school board, He recently completed a two and a half year term as the Chairman of the
Board for the American Chiropractic Association, as well, and continues to serve on the
Board of Governors as Chairman Emeritus.
Mark Lawley, who could not attend the meeting, is the other new Trustee. Commissioner
Sean Conway stated that Mr. Lawley is chief of the Mt. View Fire Department which covers
a large part of southern Weld County.
(Dave Owen was reappointed to another three year term on the Board in January.)
ANNOUNCEMENTS
There were no announcements.
Page 1 of 3 April 28,2014 NCMC Board of Trustees
CEO REPORT or COO REPORT
NCMC COO Wendy Sparks gave the following report:
• Banner health has announced that the Director of Labs position in northern Colorado
has been filled by Matt Haley. The new NoCo Medical Imaging Director is Sandy Budde,
Dan Dennie was selected as the Director Business Development Director.
• Patient satisfaction scores (HCCAPS) are hitting targets in all areas with the exception of
pain management.
• No fresh data is available regarding internal quality initiatives.
• Physician recruiting continues with interviews every week for OB/GYN, burn, pain,
orthopedics.
• March financial performance at NCMC showed a negative variance $2.2 million from
budget; this resulted in a YTD negative variance of$1.5 million. The primary reason for
the shortfalls was the impact of an adjustment to 2013 provider fee payments (CICP)
totaling $1.7 million .
• Work on the $60 million Master Campus Plan work continues. In addition to the MCP, a
new $10 million renovation of the cancer center and a $4 million upgrade to the MRI on
the 16th St. campus are underway. All told, approximately $80 million in upgrades and
renovations are planned for the near future.
Rick Sutton added that the hospital still has a high rate of readmissions for pneumonia
which is due primarily to patients who insist on going home at the earliest possible date
and, sometimes, before they are fully-healed. Often, these same patients must return
before thirty days have passed. Many of these cases relate to end-of-life situations.
NCMC, INC. REPORT
Mr. Houtchens reported the NCMC, Inc. Board has changed to quarterly meetings of the full
Board with Executive Committee meetings in the off-months. Banner's qualitative
performance under the contract is solid. INC is servicing all of its outstanding obligations
according to schedule.
VISITATION REPORTS
Credentialing and Managing Credentials
Brandon Houtchens and Dave Owen both met with Lynn Longner, Director of Medical Staff
Services, and gave the Board a short synopsis of their visits. Written copies of those
visitation reports are attached as a part of these minutes.
Outreach Department
Tom Grant met with John Ward, Director of the Outreach, in February 2014. A written copy
of his visitation report is attached as a part of these minutes.
VISITATIONS FOR NEXT MONTH— May
Mark Lawley
Michael Simone
Page 2 of 3 April 28,2014 NCMC Board of Trustees
COMMISSIONER'S REPORT
Commissioner Sean Conway deferred to Ken Schultz in reporting some upcoming changes
to the way the Board of Trustees conducts its meetings. NCMC, Inc.'s corporate counsel has
indicated that it would be in the best interest of both the INC Board and the Board of
Trustees if there were greater separation of duties between the two entities. The primary
reason for this is that INC is a 501(c)3 and the Board of Trustees is answerable in a public
forum to the County Commissioners. Mr. Schultz informed the Board that INC's counsel has
recommended that, at bare minimum, Weld County assume responsibility for posting
meeting notices and keeping minutes. Commissioner Conway indicated that, although it is
the preference of the Commissioners to hold all meetings at the County offices, in this case
it might be best to continue holding them at NCMC, if for no other reason than the ease
with which the meeting can be catered by the NCMC kitchen. Upon further discussion, it
was decided that, going forward, Esther Gesick, a Weld County employee, will serve as the
recording secretary and that the agenda for the meetings will be included with other official
postings on the County bulletin board at 115O 0 Street in Greeley. Rhonda Savoy will
continue to arrange the visitations for the Trustees throughout the year.
OTHER BUSINESS
A brief discussion was held regarding the development of a standard visitation form. A new
section will be added asking the department manager, "What is your greatest concern?"
Rhonda Savoy agreed to draft a standardized form for the future consideration and
(possible) adoption of the Board.
PLANNING SESSION
No discussion was held on scheduling a future planning session.
NEW BUSINESS
Mr. Haffner was in attendance.
ADJOURN
There being no further business to come before the Board, it was MSC to adjourn the
meeting at 1:12 p.m.
Respectfully submitted,
Rhonda Savoy
Page 3 of 3 April 28,2014 NCMC Board of Trustees
NCMC
MEDICAL STAFF SERVICES
Report to the NCMC Trustee Board
Visit by Brandon Houtchens, December 12, 2013
I met with Lynn Logner, Director of Medical Staff Services at NCMC (plus all of the Northern
Colorado Market). MSS is responsible for staff credentialing, including physician privileges, peer
review, and other medical staff functions. Its offices are on the ground floor at NCMC. Lynn came
to NCMC in May of 2011. Prior to coming to NCMC,Lynn served in a similar role with Genesis
Health System that serves parts of Iowa and Illinois. There, she had responsibilities across several
hospitals. She is a registered nurse by training and has worked in utilization/case management and
quality management.
Medical Staff Services provides administrative support to the medical staff. Responsibilities
include: Medical Staff Bylaws,Rules and Regulations,regulatory compliance, credentialing,
physician demographic updates, electronic medical staff newsletter and continuing medical
education programs. Medical Staff Services makes several rooms available throughout the facility
for physicians to use to rest during long shifts or unusual hours.
Lynn and her staff support the many departments by facilitating and recording minutes of meetings.
Lynn has reported to Dr. Stadnyk, but with reorganization of the Northern Colorado market, she
will report to Dr. Honea.
At NCMC, there are approximately 600 credentialed professionals (594 as of 12/12/13),including
medical staff(physicians; both employed and independent, telemedicine physicians, and UCH
physicians), allied health professionals (PAs;CNAs; CRNAs) and ancillary health professionals
(surgical assistants). The process of ensuring maintenance of credentials is no small task. The
number of professionals subject to the various credentialing requirements changes almost daily, and
it requires contact with professionals no longer employed by Banner, BMG, or otherwise affiliated
with NCMC. Even someone whose employment has been terminated by Banner or BMG has the
option of maintaining privileges at NCMC. Some groups,including PVH/UCH pediatricians
remain "on staff' with privileges, despite having no voting rights within the staff. Whether this will
continue or not is subject to some discussion, as their need for credential supervision creates work
for Lynn and her staff.
MSS is currently comprised of 1.8 FTE, soon to be 2.8 once a replacement is hired for someone
who recently left, and Lynn would love to have 3.8 FTE, which was the staff when she arrived.
MSS is not a centralized department within Banner, and the credentialing standards vary from
facility to facility in the Banner system. This is the product of the fact that each facility's staff have
input in credentialing standards. However,Lynn is heading up a team that is attempting to
streamline the work of other MSS departments across the system.
MSS also is involved in conduct complaints, as it receives reports of misconduct, then directs such
reports to the chair of the department involved. If the complaint isn't resolved at that level, the
Physician Health & Conduct Committee (which is comprised of all department chairs and meets
monthly) will take the matter forward.
1
MSS attends and keeps minutes at all meetings of the medical staff, 12-15 meetings/month. Some
meetings are canceled if there is no agenda; however, the Medical Executive Committee and the
Credentialing Committee meet every month.
MSS also works with recruiting, which is where a problem can arise. Recruiting might identify and
offer employment to a candidate whose eligibility for credentialing might be in question. Lynn
reported that this process is undergoing improvement, and she believes contracts for employment
provide that employment is contingent upon issuance of NCMC privileges.
MSS must know and ensure compliance with CMS (Centers for Medicare and Medicaid Services)
and JCAHO (Joint Commission Accredited Health Organizations) standards, and unlike other
Banner facilities, NCQA (National Committee for Quality Assurance) standards,which apply under
the terms of the Banner/Kaiser relationship. Lynn reported with some satisfaction that NCMC has
successfully undergone two NCQA audits.
Evaluation of MSS is difficult, since it can't easily be judged by quality, by financial performance, or
by other standards employed by Banner to evaluate its departments. Lynn can demonstrate the
number of credential/privilege requests she and her staff process, and she is considering tracking the
speed at which MSS processes temporary privilege requests. She has organized the responsibilities
of her staff to increase direct contact between her department and staff,which she believes has been
a success. She is very appreciative of her staff and her leadership at NCMC.
I enjoyed my time with Lynn and found her to be an excellent representative of NCMC.
Brandon B. Houtchens
2
f eb. :3,2014
Memorandum For: NCMC Board of Trustees
From: Trustee David Owen
Subject: Trustee Visit, Medical Staff Services
On Feb.14, 1 visited with Lynn Longner, Manager, Medical Staff Services. Medical Staff
Services is a small but unique unit which is common to most hospitals. Until recently,
this unit was exclusive to NCMC. Since implementation of Optimization, however, and
the formation of Banner Health Northern Colorado, it has been given the added
responsibility for McKee Medical Center (MMC) and the new Ft. Collins hospital. Vls.
Longner's supervisor is Dr. Honea, CMO at MMC. She now has four employees but will
have six when the new hospital opens---there will he two employees at each site.
The unit's mission is to support medical staff and staff leadership with efficiency,
accuracy and consistency. The unit's main responsibilities include verifying the
credentials of all physicians, physician assistants and nurse practitioners who wish
hospital privileges. Currently. the unit has about 600 persons in its system--not all are
employed by Banner Health. Nurses. other than NP, are administered by Banner Human
Resources. The unit also is responsible for recertification which is accomplished every
two years by the Credentials Committee which just met. All files must meet approval by
the respective department chair.
When new medical staff is hired or desires privileges, he or she undergoes a mini check
which includes a background check for criminal history as well as their professional
credentials---in other words, they are what they say they are! Their malpractice insurance
is checked as well as their license to practice. All together, it takes about five months to
get someone fully credentialed.
Every six months, data is examined on each of the medical staff and compared to his or
her peers for such trends as complication rates, patient length of stay, patient costs z.nd
mortality rates. If there are patient complaints or other adverse info, the person is required
to meet with his or her department chair. A hearing process would he held for serious
cases such as malpractice or complaints received from the Colo. Dept. of Regulatory
Agencies.
Persons concerned are charged a fee for the two year recertification process.
Foreign trained personnel are required to undergo a testing process plus a two year
residency.
Ms. Longner is also responsible for the NCMC medical library which has one employee
some reference books and a computer. I did not visit it.
Ms. Longner and her staff are working on forms standardization for the credentialing
process. I was impressed by her knowledge and enthusiasm for her job. She has worked
for Banner for about three years having come from a similar position in another state.
TRUSTEE REPORT
FEBRUARY 12, 2014
VISIT WITH OUTREACH DEPARTMENT
TOM GRANT
I had the pleasure of visiting with the Outreach Department. The department consists of only
five employees but serves a tri- state region(Colorado,Nebraska and Wyoming) and the very
important function of getting medical services out to our rural communities. The Department is
headed up by John Ward, who has been with Banner since 1991 and he oversees this department
which in addition to rural outreach also runs an amazing bum center. The Outreach Department
is, at least in part, the brain child of Dick Stenner, who helped start the program back in the
1970's.
I._4)ri Lehman has been with Banner for the past 12 years and has been with the Outreach
Department for about two years. She is the organizer in the department, coordinating events and
schedules and performing numerous administrative functions. Also in this department is Allison
Miller, Outreach Program Manager. Allison has been with Banner for 15 years and spends much
ahc time coordinating and promoting the Western States Burn Center. The last two employees
rounding out this department are the very important pilots that transport doctors and equipment
to the rural areas so the top quality care can be provided to these traditionally underserved
populations.
The Western State Burn Center is a state of the art bum treatment center, which is located right
her at NCMC in Greely. It serves patients from an eight state region and is in a 12,500 square
foot facility that has 14 beds. This center is recognized as one of the top facilities of its kind in
the Country. The beds in this department can also be used for ICU overflow.
Outreach has also pioneered the use of high definition cameras that can allow a doctor in Greeley
to evaluate a wound on a patient is Sterling without having to make the trip to that location. This
saves time and money, and most importantly has the potential to save lives. This allows doctors
to make an immediate diagnosis and start a treatment regiment right after viewing the patient
through the camera.
I have attached some information provided by the Outreach Department for your review. The
material provides information on the geographic scope of the outreach and contains the
department's goals and objectives. John Ward and his staff appear to be hard working
enthusiastic employees who are providing very important services to our region.
2/12/2014
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NCMC
Outreach Services,
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North Colorado Medical Center
Outreach Services
Goals & Objectives
• Goal/Mission: Make a difference in people's lives through
excellent patient care in rural communities
• To increase access to health care via ...
— Physician outreach clinics
— Physician consult and transfer line
— Tele-medicine clinics/Med Evac
• To increase education to rural providers/staff
— CME's, brown bag lunches,conferences,ABLS/ACLS
— On-site training classes—trauma,EMS
— QA review, including trauma
• To promote a integrated delivery system within our service area
• Promote NCMC's services to providers/families for transfers
15 TOP S' AGE7
Banner Health
BMG Outreach Clinic
Providers & communities
• 31 physicians and 1 FNP provides services to 14
communities
Bridgeport,NE Brush,CO
Fort Morgan,CO Grant, NE
Haxtun,CO Holyoke,CO
Julesburg,CO Ogallala, NE
Sidney, NE Sterling, CO
Windsor,CO Wray,CO
Yuma,CO
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2/12/2014
BMG Outreach Specialty
Clinics
• 90 specialty clinics per month
Behavior Health Cardiology
Endocrinology Gastroenterology
General Surgery Medical Oncology
Neurology Orthopedics
OB/GYN Pain/Vasucular
Podiatry Pulomonology
Radiation Oncology Urology
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Identifying Outreach
Opportunities
• CEOs/Provider requests
• Market supply and demand analyses
• Area information sheets
• Market share
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2/12/2014
Outreach Marketing Materials:
The Audience
• Patients
• Families
• Communities
• Providers
• Hospital staff
• Clinic managers/staff
• Facility CEO's/C-Suites/Boards
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Banner Health Clinic Outreach Clinic Locations
Location Specialty BMG/CVI Physician Frequency Appointment
Bridgeport,NE Pulmonology Michael Shedd I St Friday/ma (308)262-1755
4t" Wednesday/ma
Pain/Vascular Timo Quickert Ix/month (308)262-1616(ask for
Tiffany)
Brush,CO Cardiology Harold Chapel,Lin-Wang Dong,Cynthia Gryboski, I Mon&Wed/weekly (970)392-0900
Ahmad Shihabi ,
I Pulmonology Gregg Golden 1St Tuesda I(970)842-6740
Rob Janata 4th Tuesday (970)392-2026
Neurology Christy Young 2nd Thursday (970)350-5612
OB/GYN Paul Hiratzka 3'd Thursday (970)352-6353 —
Fart Morgan,CO Cardiology Lin-Wang Dong,Cynthia Gryboski,Ahmad Shihabi frrday/3x/ma (970)392-0900
Neurology Christy Young 1x/month (800)303-9128
OB/GYN Paul Hiratzka,Phillip Garza I'r Tues,&3 rd Thurs, {970)352-6353
Pulmanology Greg Golden 1st Wednesday (970)842-6740
Grant.NE Orthopedics Van Wahlgren 2 n°&4° Thursday (308)352-7200
Haxtun,CO Cardiology John Drury Tues/1x/mo _ _ f970 526-8181
Holyoke,CO Cardiology ,James Beckmann Tues/3xlmo (970)392-0900
Cardiology John Drury _Tues/2x/mo (970)526-8181
Pulmonology Michael Shedd 3'd Tuesday{P.M.) (970)854-2241 Ext.316
Neurology Barbara Hager i'S Thursday (970)350-5612 I
'OB/GYN-- Sidney Adler — Vary 1/mo (970)854-2241
rPodfatry Lorin Brandon „lx/month (970)542-4700
Urology llamas Wolach 1 sr Wednesday (800)2814964
Julesburg,CO General Surgery Nell Banga 1St Wednesday )970)522-2264
Pulmonology Michael Shedd 3 rd Tuesday(A.M.) 1970)474-3323 _
Ogallala,NE Cardiology John Drury _ rues/Wino (308)284-7230
Gastroenterology Mark Rosenblatt 3 r°Wednesday (308)284-4011
Pulmonology Michael Shedd 3p Monday(P.M.) (308)2844011
Oshkosh,NE Orthopedics Van Wahlgren 1't&3rd Thursday (308)772-3283
Sidney,NE Pulmonology Michael Shedd i�Frrday/mo (308)254-5825
4"' Wednesday/mo
Sterling,CO Neurology William Shaffer,Todd Hayes Tues&Thurs/2x/mo ,(970)350-5612
Cardiology John Drury Mon,Wed-Fri (970)526-8181
Cardiology Harold Chapel Tues 1x/ma (970)392-0900
Medical Oncology Ariel Soriano Every Monday (970)378-3894
_Pulmonology Michael Shedd 3'd Monday(A.M.) (970)526-8175
Radiation Oncology Elizabeth Ceilley,Brian Fuller,Jeff Albert Every Wednesday (970)526-5555
Windsor,CO Behavior Health Patty Al-Adsani Every Tuesday&Thursday (970)674-3153
Endocrinology 1Tracy Hergert,FNP Every Wednesday (970)686 5646
Gastroenterology Yazan Qwaider,Mark Rosenblatt,Ahmed Sherif Tuesdays (888)557-0506
T
OB/GYN Nell Allen,Alana Revaal 2"&4 t"Tues.AM
Orthopedics Kelly Sanderford Monday(every other P.M.) (97D)348-0020
Wray,CO Cardiology Paul Hurst Cecilia Hirsch 2x/month (970)392-0900 —
Podiatry Thomas Atwood 2x/month X970)353-5854
Yuma,CO Cardlolg Paul Hurst,Cecilia Hirsch 2x/month 1970)392-0900
Neurology Christy Young 1"Tuesday (970)350-5612
OB/GYN Sidney Adler 4"'Monday (970)848-3896
Urology fames Wolach 3 d Wednesday (800)281.1964
1/31/2014
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