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HGH Board Brief August 27, 2019

Trustees present: JoAnn Casalez, Chairman; Michelle Miller, Secretary; Bill Hammargren; Ken Tipton; and Gene Hunt. Trustees not present: Jennifer Hood.

Medical Staff-Hospital Department Reports

Great Basin College Foundation Update

Great Basin College Foundation Director Matt McCarty told HGH board members that just three hours prior, he attended a meeting where Van Woert Bigotti, a Reno-based architectural firm, was selected to complete pre-design services for the Great Basin College Health Sciences and Technology Building. Matt noted that Newmont Mining Corporation donated $100,000 to the project, which the college will use to pay for those pre-design services. He said the architects feel confident a $7 million building can be built "quickly." Matt said the firm will take between 90-120 days to develop a pre-design plan. Following, the college anticipates releasing a Request for Proposals for contractor services in early 2020, and hopes to break ground in June 2020. Matt noted that enrollment at the college is up.

Medical Staff Report

Dr. Paul Gaulin, Humboldt General Hospital's Chief of Staff, reported that he attended the sentencing hearing for Dr. Shouping Li. He said the judge was aware of Dr. Li's care in Winnemucca and was complimentary of the service he has provided to the community. Dr. Gaulin said the judge agreed Dr. Li's actions were not pecuniary or malicious in nature. Dr. Gaulin said Dr. Li's situation is a strong reminder of Humboldt General Hospital's need to provide pain relief help to patients who legitimately suffer from chronic pain. HGH Interim CEO Karen Cole said an agenda item later in the meeting will address that very concern.

Dr. Gaulin also noted that mental health issues comprise 50 percent of medical care and wondered how the hospital can better care for patients with those issues.

He also expressed gratitude that a second CRNA will begin working at the hospital. He said it has been a "stretch" to believe that one CRNA could handle all the cases that the hospital does.

Dr. Gaulin also complimented HGH EMS Rescue Chief Sean Burke and his team for their work assessing a serious trauma case and providing transfer.

Administration Department Report: CEO

HGH Chief Financial Officer Sandi Lehman shared that two ambulances that were previously on loan to the Reno Fire Department for training purposes have been returned to HGH.

HGH Practice Administrator Robert Johnson discussed a potential OB and Women's Health Clinic in McDermitt that would be serviced by an HGH midwife. He said he has spoken with the Fort McDermitt Pauite and Shoshone Tribe physician there and he is hopeful HGH can be helpful in coordinating better healthcare outcomes for expectant mothers. A clinic in McDermitt could also provide routine gynecological care. Robert said HGH hopes such a clinic could stop or at least dramatically reduce the number of women who present at the HGH Emergency Department in labor without having had any prenatal care. Robert said HGH will not move forward, however, until the tribe resolves its delinquent medical bills.

Dr. Janhunen

CEO Cole shared that Dr. Veronica Janhunen has been practicing for one month now in the HGH Pediatric Clinic. She has been very busy, seeing an average of 20 patients a day, and the hospital is very happy to have her on staff. Currently there is a one-month wait for patients to schedule an appointment.

Additionally, CEO Cole updated board members on current physician recruitment efforts:

  • Dr. Alex Curtis, a family practice/OB physician, will arrive at HGH on September 3.
  • Dr. Rommel Adajar, an internal medicine specialist, is expected to arrive at HGH on October 7.
  • A family practice/OB physician has agreed to a site visit September 15-17. The Wisconsin Critical Access Hospital, where she has worked since 2012, is now closing its OB unit. Her husband is an engineer and she has one son in college.
  • A family practice/OB physician is currently completing a 1-year high-risk surgical fellowship in Spokane, Washington. He will be available in fall 2020. His physician wife, also a family practice/OB physician, is currently completing a family residency program. Both doctors are looking for a rural opportunity. They are familiar with the Winnemucca area and are very interested.
  • A Washington family practice/OB physician is also looking for a practice opportunity where she can perform C-sections. Her husband is a paramedic and they have one daughter.

CEO Cole updated the board on the upcoming Cerner conversion process. She said the hospital's contract project management group, Wipfli, has been invaluable in maintaining a vigorous implementation schedule as well as identifying potential issues and resolving concerns. HGH staff members have greatly increased their workload in terms of trainings, meetings, data submission, weekly calls and more. August 6-8, clinical staff began integration testing; financial staff followed on August 13-16. The next phase of integration will take place the weeks of September 9 and 16.

CEO Cole said the Cerner project does present some risk issues, specifically with regard to Medicaid long term care billing. She said Cerner partners with Ameracare for Medicaid billing. Humboldt General Hospital will be the first Critical Access Hospital in Nevada to use the software program. CEO Cole said Medicaid billing in long term care is a small but very important part of what the hospital does, so adding the Ameracare component is critical. Board Secretary Michelle Miller noted that CEO Cole and HGH Chief Financial Officer Sandi Lehman have both poured over massive amounts of information and exercised great care in arriving at their Cerner-related decisions.

The former Physical Therapy and Cardiac Rehabilitation departments

HGH Plant Facility and Safety Director Duane Grannis updated the board on the transformation of the Physical Therapy and Cardiac Rehabilitation departments into the new Pharmacy Department. Duane said it is great having Sletten Construction back on site, led by Rick Reynolds. Already, crews have 90 percent of the demolition work done, including two days of cutting concrete. They are preparing to begin framing walls in the next few days. There have not been any issues with infection control.

CEO Cole also updated the board on the coming launch of the Optimum human resources program. Humboldt General Hospital plans to go live with its first payroll on the new system in October.

Additionally, CEO Cole said the hospital is working with Nevada Rural Hospital Partners to get quotes for a new employee health insurance plan. The hospital has been with Prominence for several years; HGH also will be looking for vision insurance that is accepted by local providers.

CEO Cole said a new CRNA, Landon Mauritsen, will begin work at HGH September 16. The hospital is attempting to recruit a third CRNA or CRNA group to avoid hiring a temporary provider. The money spent on one locum CRNA will actually cover the cost of hiring two additional permanent staff members.

Consent Agenda

Board trustees approved the meeting minutes for the June 25, 2019 meeting; Chairman JoAnn Casalez abstained from the vote. Additionally, board members approved medical staff applications for appointments, reappointments, provisional and temporary privileges for 14 medical providers.

Financial Reports

HGH Chief Financial Officer Sandi Lehman shared highlights from the June and July financial statements.

For June, patient days were over budget for all areas in the hospital with the exception of clinic visits. Month-to-date net loss from operations was only $178 compared to a budgeted loss of $2.3 million. June's operating revenues were higher than budgeted by approximately $1.4 million; month-to-date net loss was $204,559 compared to a budgeted loss of $1.9 million. Month-to-date non-operating revenues/expenses included the first donation installment to Great Basin College of $333,333. Year-to-date net income was $4.2 million compared to a budgeted loss of $969,000. Sandi said June's financials do not include any audit adjustments for FY19.

For July, patient days and OR cases were under budget for the month, as were clinic visits. Utilization in all other areas of the hospitals were over-budget. Net income from operations for July was $98,558 compared to a budgeted income of $83,099. July operating revenues were lower than budget by approximately $377,000 and operating expenses were below budget by approximately $148,000. Net income for the month was $340,011, which was approximately $138,000 below budget.

Sandi said the hospital's auditors will be completing their "field work" at HGH the week of September 23. Additionally, she is hoping a review of the hospital's chargemaster will be complete by October.

Sandi reported that the hospital's accounts receivable days are 90.05, which is down from June's 90.16 but up from May's 87.11. She said her team is working to clear $800,000 in outstanding balances with 11 long-term care residents. Those efforts have included three visits to Carson City and re-submission of those billing requests. Additionally, the hospital is working with the Fort McDermitt Paiute and Shoshone Tribe regarding outstanding balances there.

Sandi said the hospital also is focusing on reducing third party insurance balances and developing an action plan with the hospital's current biller, HRG, for quicker resolution of billing difficulties. Trustee Bill Hammargren asked if the hospital has received more complaints regarding HRG since it notified the company it would be terminating its services. He said his own experience with the company has not been positive. Secretary Michelle Miller said she has received complaints as well. Sandi said she was not aware of an increase in complaints.

Board Secretary Miller inquired regarding the hospital's general fund balance. She asked when the hospital plans to move excess funds to an account that accrues interest. Sandi said the hospital's balance in July was $8.9 million; however, the hospital must maintain an average daily balance of $8 million in order to avoid transaction fees. Sandi said she is working with financial advisors to explore ways to avoid those fees while maximizing investment of the hospital funds. Trustee Miller said she would like to see a policy regarding when the hospital should transfer funds. Trustee Gene Hunt agreed. CEO Cole suggested such a policy could be discussed at the September meeting of the board. Sandi said she will discuss that and other pertinent issues with the hospital's auditors in preparation for the next board meeting.

Business Items-Other Reports

1. Hospital Administration-Pharmacy / proposal to purchase casework for pharmacy remodel project / Administration-Pharmacy Director - CEO Cole told board members that while the Pharmacy Department expansion and remodel has been completely budgeted, the storage space still must be designed and equipped. Hamilton Casework Solutions submitted the low bid of $183,398 to do the work; however, trustees agreed to table this item until CEO Cole and Pharmacy Director Dave Simsek can look at the numbers and see if there are items, such as desks, that can be purchased at a lesser price. CEO Cole believes the hospital can save up to $80,000 by substituting some pieces.

The hospital's new 3D Mammography machine is on the left; the new Dexa unit is on the right.

2. Hospital Administration-Radiology / proposal to purchase mammography and bone densitometer equipment for the radiology department / Administration-Radiology Director - Board members unanimously approved the purchase of Digital Breast 3D (Tomosynthesis) and Bone Densitometry machines for the Radiology Department at a combined cost of $328,000. Both units are at their respective ends of life; the Dexa stopped functioning at the first of August.

3. Hospital Administration / proposal to adjust CTA Architects fee for services related to the pharmacy remodel project / Administration-Owners Representative - HGH Owners Representative Mike Sheppard explained that CTA Architects' original fee structure for the current Pharmcy-PT expansion remodel was based on a proposed $1 million project; however, the project ended up bidding over $2 million. Accordingly, CTA had to revise its fee structure. Board trustees unanimously approved an additional $90,000 in architectural fees.

4. Hospital Administration/ proposal to renew agreement for payments to CTA Architects on a time, materials and cost reimbursement basis for miscellaneous architect and engineering services / Administration - The hospital board unanimously approved a renewed agreement with CTA Architects for various miscellaneous services, such as recommendations regarding carpeting and interior design. CEO Cole reminded board members that the hospital's first expansion remodel took place nearly 10 years ago and the new finishes from that time have become worn and dated. What's more, the same finishes are largely not available at this time.

5. Hospital Administration / determination that airport vehicle is no longer required for public use and authorization to dispose of vehicle / CFO-Administration - Hospital trustees determined that a 1991 ford Explorer that has been kept at the Winnemucca Municipal Airport for transportation of visiting specialists is no longer required for public use. In answer to questions regarding the disposition of the vehicle, HGH CFO Sandi Lehman said the vehicle will be put out to bid to HGH employees.

6. Hospital Administration / proposal to use the professional services of and enter into an independent contractor agreement with Andrew Wesely, M.D. to provide pain management services / Administration - Board trustees unanimously approved a proposal to enter into an agreement with Andrew C. Wesely, MD, to provide a pain management clinic at Humboldt General Hospital. CEO Cole noted that Dr. Wesely's clinical experience includes expertise and skills in the full spectrum of pain management treatment including (but not limited to): medication management, therapeutic spinal and peripheral nerve joint injections with imaging guidance, pain pumps, kyphoplasty, and the management and treatment of common musculoskeletal and sports medicine injuries and disorders. Dr. Wesely is currently the director of pain management services at the William Bee Ririe Hospital in Ely. CEO Cole said Dr. Wesely would initially provide clinic services two days/month. As patient volumes rise and Dr. Wesely's schedule permits, his clinic days may increase.

7. Hospital Administration / proposal to use the professional services of and enter into an independent contractor agreement with Alvaro Galvis, M.D. to provide pediatric services / Administration - The board unanimously approved an agreement with Alvaro Galvis, MD, to provide newborn nursery call coverage up to seven days a month. The agreement also includes a one-time finder's fee of $25,000, which will be recovered within three months.

8. Hospital Administration / proposal to use the professional services of and enter into an independent contractor agreement with Bejal Patel, M.D. to provide pediatric services / Administration - The board unanimously approved an agreement with Bejal Patel, MD, to provide newborn nursery call coverage up to seven days a month. Dr. Patel comes highly recommended by HGH Pediatric Specialist Veronica Janhunen.

9. Hospital Administration / proposal to use the professional services of and enter into an independent contractor agreement with Charles Stringham, M.D. to provide collaboration and oversite services for mid-level providers / Administration - The hospital board approved an agreement with Dr. Charles Stringham to supervise Humboldt General Hospital's mid-level providers. CEO Cole said Dr. Robert Westling has provided that service for approximately six months, but recently notified the hospital he would not longer be available. Dr. Westling, who spoke from the audience, said he was "blindsided" by the proposal to bring on Dr. Stringham. He said he has attempted to formalize contract negotiations regarding the role for six months but was unable to and was advised by his lawyer to stop. "But I never said I didn't want to do this." He said he has been very busy providing medical direction to Harmony Manor and Quail Corner; he also said he has had a problem with the mid-level providers' compliance. Further, Dr. Westling said he does not believe Dr. Stringham qualifies to supervise the mid-level providers as he appears to lack pediatric and gynecological experience. HGH Chief of Medical Staff Paul Gaulin said that contracts like the one between the hospital and Dr. Stringham "affect multiple relationships" and can have a bearing on medical care. He said those contracts may actually constitute a form of granting hospital privileges to providers and should be reviewed by medical staff. HGH Vice Chief of Medical Staff James Langevin said Dr. Stringham has not been to a medical staff meeting in three years and has not been subject to the hospital's peer review process. "How are you going to ensure that Dr. Stringham complies?" he asked. CEO Cole said the contract between the hospital and Dr. Stringham does not establish what privileges the physician will have; only medical staff can decide that. Instead, she said the contract simply establishes a relationship between the hospital and Dr. Stringham. Secretary Michelle Miller added that if medical staff does encounter a problem with Dr. Stringham's ability to medically carry out the contract, then "there is no penalty to rescind the contract." Additionally, CEO Cole said other issues have contributed to the hospital's decision not to continue its relationship with Dr. Westling. Trustee Hammargren agreed it's a good time for physicians to "share the workload." Following several attempts at motions, the agreement with Dr. Stringham ultimately passed with Trustee Harmmargren, Secretary Miller and Chairman Casalez voting aye and trustees Ken Tipton and Gene Hunt voting nay.

10. Hospital Administration / proposal to use the professional services of and enter into a contract with Sleep Medicine Associates, Inc. to provide sleep medicine services / Administration - The hospital board unanimously approved an agreement with Sleep Medicine Associates, Inc., to provide sleep medicine services at Humboldt General Hospital. The company will provide all services and HGH will do the billing. CEO Cole said the program is not a large revenue generator, but it will bring this important service to the community.

11. Hospital Administration-EMS/Maintenance / proposal to purchase two Cummins 20KW generators to provide backup power to emergency operations and communications center / Administration-Maintenance Director - Hospital trustees unanimously agreed to the purchase of two Cummins emergency generators at a total cost of $17,708. The generators will provide emergency power to the Emergency Operations Center (in the IT Classroom) and the Communications Center.

12. Hospital Administration-Human Resources / determination of critical labor shortage of Radiology Tech position for radiology department to allow reemployment of retired public employee / Administration-Human Resources Director - The board agreed to table to the agenda item to designate a Radiology position as a critical labor shortage, which would allow the hospital to hire someone who has previously retired. Board Trustee Bill Hammargren expressed concern the hospital has not done enough to show good faith in trying to recruit for the position.

Trustee Comments

Trustee Gene Hunt said he was thrilled with the pain management item on the agenda. He said his personal circumstances would welcome such a clinic.

Secretary Michelle Miller said she would like to see "traction" on the medical staff and board bylaws.

Chairman JoAnn Casalez thanked hospital staff for all their hard work leading up to the implementation of the Cerner electronic healthcare record system.

Next Meeting

The Humboldt County Hospital District Board of Trustees will meet next in regular session at 5:30 p.m. Tuesday, September 24, in the Sarah Winnemucca Conference Room.

Meeting agendas, board minutes and more will be/are available at: