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HGH Board Brief February 26, 2019

Trustees present: JoAnn Casalez, Chairman; Michelle Miller, Secretary; Bill Hammargren, Jennifer Hood, Gene Hunt and Ken Tipton.

Medical Staff-Hospital Department Reports

Emergency Department Services Report

Emergency Department Manager Robyn Dunckhorst discussed patient satisfaction results and quality/performance improvement.

Previously, the hospital contracted with the HealthStream patient satisfaction survey system with disappointing results. In December 2018, the ED switched to Qualitick, a real-time survey system that is designed to capture patient feedback during the discharge process. Robyn said patient satisfaction results are instantly gathered and nursing leadership is advised immediately of any issues that need to be addressed--and the results have been impressive. Consider the following results from 283 patients in December and 228 patients in January.

  • Would you recommend our ED? December - 95% yes; January - 98% yes.
  • Overall satisfaction: December - 66% very satisfied and 32% satisfied; January - 70% very satisfied and 25% satisfied.
  • How satisfied were you with the doctor? December - 67% very satisfied and 26% satisfied; January - 70% very satisfied and 22% satisfied.

Robyn noted that Qualitick's benchmark for satisfaction is 85%; the goal for the HGH ED is for 85% of patients to be "very satisfied." She also said that the Centers for Medicare and Medicaid Services would like to see a 10% sample of patients; Qualitick strives for a 20% to 30% sample of patients.

Robyn also discussed the ED's door to EKG times. She said the ED's nursing staff wished to lower the time it takes for a patient experiencing chest pain to receive an EKG. The national benchmark is less than 10 minutes from arrival to EKG. HGH's average for 2018 is 2.67 minutes.

HGH Emergency Department
Nursing Report

HGH Chief Nursing Officer Darlene Bryan referred to the hospital's long-term care report in the board packet and asked board trustees to contact her with any questions. She then addressed some public comments from the beginning of the meeting regarding the admissions process at Harmony Manor and Quail Corner.

Darlene said the hospital tries to be consistent in its admissions procedures. She said, "We are a five star facility and we want to maintain that." She said staffing issues can have an effect on the hospital's ability to admit patients, as can a family's ability to pay, the nature of a patient's health, and more.

Trustee Bill Hammargren said the admissions "conversation" has been going on for years. He said that was partly the reason for building Quail Corner, so that local residents would not need to be sent to out-of-area facilities for care. Regarding current residents being sent out-of-area, he said, "We need to fix this; we need to treat people fairly." He said it is time for the hospital to look beyond current policies or procedures. "We need to have a better response."

Darlene agreed the hospital must look at the "big picture." However, she said long-term care will never be able to admit every person who has lived in Winnemucca, but that the hospital will do what it can.

Board Chairman JoAnn Casalez said if there are empty beds in both Harmony and Quail, then regardless of the reasons, long-term care must understand what it needs to do to fill those empty beds.

Trustee Michelle Miller wondered why the hospital is able to meet staffing needs in other areas of the hospital but not in Harmony or Quail. She said she understands it is a complicated process, but it shouldn't take six months to solve. "If we use those same policies, then why?"

Darlene noted that long-term care hosts a weekly admissions committee meeting. Families must comply with a list of requirements. She said staff attempts to help families comply. She said there is an admissions list for the two facilities, "but that doesn't mean they're waiting to come in." Some don't have the items they need; others are not ready for a long-term care facility.

Interim CEO Karen Cole said the long-term care admissions issue is "something we all need to revisit." She suggested it might be wise to have a member of the board work with the admissions committee. Trustee Gene Hunt said he would be happy to take part in the discussion. He also suggested cross-training nursing staff to work in long-term care; Darlene said nursing staff are already cross-trained.

Trustee Jennifer Hood suggested that patient navigators help families as they go through the admissions process. She worked with a navigator at another facility -- an experience she said "meant everything" as it eliminated her chaos and confusion. Darlene said the hospital has a social worker, a case worker and long-term care director who function in that capacity.

Chairman Casalez said the hospital needs to do more to educate the community regarding the long-term admissions process. Trustee Ken Tipton said well-defined policies and procedures will help. Darlene said one point of contact for prospective residents would also help.

A sample advertisement for the HGH Nurse Health Line, in partnership with REMSA.

Nurse Health Line Report

HGH Director of Community Education and Development Nicole Maher updated the board on the Nurse Health Line, which the hospital launched, in partnership with REMSA, in May 2018.

Nicole reported that 294 people have called the line over the past eight months. Of those, 45.8% were calls on behalf of children (ages 0-18); 47.3% were calls from adults (ages 19-64); and 6.9% were calls from seniors (65 and older). Abdominal pain was the most common complaint for callers, followed by head injury, vaginal bleeding, insect bites, cough/toddler, abdominal pain/child, diarrhea, diarrhea/toddler, ear problem, and headache.

Nicole also showed the difference between "caller predispositions," or what callers intended to do if they had not called the nurse health line, and the actual recommended level of care. Thirty-four callers, for instance, intended to stay at home for self-care, when their recommended protocol was to go to the Emergency Department, the Walk-In Clinic or their primary care provider.

EMS Services Report

HGH EMS Rescue Chief Sean Burke discussed the recent activities of the hospital's Security Work Group. He said the team has consolidated the door lock programs, conducted a physical security inspection, made perimeter security improvements, improved the facility's camera system, reviewed the hospital's security policy, and hosted approximately 70 people for an active shooter training organized by HGH Pharmacist Dave Simsek.

Chief Burke said future efforts will see both an active shooter tabletop exercise in May and a field exercise with local law enforcement in the fall. The team will also continue to oversee security guards and door locks, as well as panic alarm and security lighting upgrades, employee training, and a visitor access policy.

Administration Department Report: CEO

HGH Interim CEO Karen Cole updated the board on physician recruitment efforts.

  • Alex Curtis, MD. Alex Curtis, MD, has signed an agreement with the hospital to provide Family Practice OB services; his medical license application for Nevada is slated for consideration in June.
  • Roger Brecheen, MD. Roger Brecheen, MD, has extended his agreement with the hospital for 18 months. He will continue to provide OB/GYN services, including minimally invasive gynecological surgeries.
  • Sara Thorpe, DO. Sara Thorp, DO, has contracted with Dr. Brecheen to provide Family Practice OB services for one week each month over the next 18 months. Dr. Thorp is interested in coming to the hospital full-time at the end of her 18-month contract with Dr. Brecheen.
  • Felipe Gomez, MD. Felipe Gomez, MD, completed an OB/GYN residency in Mexico as well as a Family Practice residency in the United States. He came for a site visit February 23-24 and will be making a decision soon regarding his future employment.
  • Shannon Servin-Obert, DO. Shannon Servin-Obert, DO, is seeking a rural hospital/OB position. She may come for a site visit.
  • Sheena Dover, MD. Sheena Dover, MD, will complete a Family Practice OB Fellowship in 2020. CEO Cole will speak with her March 1; she may schedule a site visit at the end of March.
  • David Masuck, MD. David Masuck, one of HGH's Rural Family Medicine Residency physicians, submitted a letter of intent to work at Humboldt General Hospital following his graduation in June 2020.
  • Pediatrician. A pediatrician will be available August 2019. CEO Cole will present that physician's letter of intent at the March meeting of the board.
  • Internal Medicine. CEO Cole also shared that she will begin recruiting an Internal Medicine specialist immediately in order to improve patient access to care. She said IM physicians are experts in the diagnosis and treatment of chronic illness, and in health promotion and disease prevention.

CEO Cole also discussed a comprehensive quality assurance/performance improvement program for both the hospital and the medical staff. She said medical staff must perform peer review/professional peer evaluation, as required by statute. This process provides for monitoring the performance of all members of the medical staff. The process includes internal and external reviews, and assists in the initial and re-credentialing of providers.

CEO Cole also discussed a feasibility study for local sleep medicine studies; telepsychiatry; and chronic care management, transitional care and community paramedicine.

Financial Report

HGH Chief Financial Officer Sandi Lehman shared highlights from the November and December financials. November had an operating loss of approximately $900,000, while December saw an operating profit of approximately $31,000.

For January, patient days were under budget month-to-date by 1.39%, and year-to-date by 8.34%. Surgical cases were over budget month-to-date by 16.13% and year-to-date by 11.79%. Rural Health Clinic visits were under budget month-to-date by 9.98% and year-to-date by 17.84%. Operating income for the month was up 256.7% and net income for the month was under budget by 7.84%, at just over $1 million.

Sandi also shared that current days in accounts receivable are 79.4; the target is to reduce the number of days to less than 70 by September 30, 2019. She discussed the hospital's strategy to reduce those days, including the current 50% discount promotion on all self-pay balances happening now through May 15. To date, the Business Office has resolved over 800 accounts and collected $168,000.

Sandi discussed the Fiscal Year 2020 Budget with trustees. Staff members are currently submitting their budget information; they will meet in budget talks next week. Copies of the draft budget will be distributed to the CEO and board trustees on March 11; the board will hold a budget workshop on March 30; and the board will go over any final revisions to the budget at an April 9 meeting. The FY 2020 Public Budget Hearing will take place on May 28. The final budget must be submitted to the Nevada Department of Taxation by June 1.

Sandi also invited Nick Thate, the Cerner conversion project manager, to update the board. Nick said Cerner's kickoff site visit will take place the week of April 1; the program's scheduled "Go Live" is November 11, 2019.

Consent Agenda

The board approved the Consent Agenda, including approving the board meeting minutes for January 22, 2019; a proposal to approve a mutual aid agreement to respond to medical emergencies in Malheur County, Oregon; a proposal to purchase an ambulance monitoring system; and a proposal to replace a chiller condenser coil. The voting was unanimous.

Business Items-Other Reports

1. Hospital Administration-Maintenance / proposal to procure services of RF MacDonald to replace-rebuild the unit #2 boiler rear insulated panel and high pressure switch / Maintenance - HGH Maintenance Director Duane Grannis requested $19,985 to replace the unit #2 boiler rear insulated panel and add a high pressure switch. Board trustees unanimously approved the request as presented.

2. Hospital Administration-Maintenance / proposal to enter into agreement with Trane to provide services to review and implement utility rate structure changes with NV Energy to ensure optimal energy savings / Maintenance - HGH Maintenance Director Duane Grannis said that Trane may be able to negotiate a lower rate for the hospital with NV Energy; currently, HGH is at a single rate use 24/7 with no reduction for non-use time. Duane said Trane obtained a significant reduction for the Peppermill Casino in Reno; Trane has promised it can save the hospital at least $45,000 a year. Board trustees unanimously approved the agreement as presented.

3. Hospital Administration / proposal to amend Medical Staff Bylaws / Administration - Interim CEO Karen Cole said the most recent medical staff bylaw revisions were submitted to the board in August; since that time, there has been some consternation with moving forward. She consulted with the same attorney who reviewed the hospital's medical staff bylaws the last time there was a change. He reviewed the current revisions recommended by medical staff and suggested the board move forward in adopting three specific sections of the documents in order to allow all physicians to be more involved as officers. As to the remaining bylaws, CEO Cole suggested that the board schedule a mini retreat where board members, medical staff and hospital administrators can discuss and come to an agreement on their governance roles. CEO Cole will work on a proposed date. Board trustees agreed to pass the proposed revisions to sections 3.01, 3.02 and 3.03 of the HGH medical staff bylaws. The vote was unanimous.

4. Hospital Administration / proposal to implement an obstetrics policy / Administration - Due to recent changes in OB and neonatal providers at Humboldt General Hospital, Interim CEO Karen Cole said the hospital has a particular interest to ensure that there is an OB call schedule. CEO Cole introduced a new policy that says "if you provide OB services here, you will participate in a call schedule." She said this means that if a provider is leaving town, there should be a "good hand off" of that provider's patients, and a sharing of the call overall. She said this is standard practice at other hospitals. She also said call coverage is a very important aspect of recruiting other physicians. Potential candidates are looking for a department that shares call among three or four providers. Board trustees unanimously approved the obstetrics policy as presented.

5. Hospital Administration / proposal to amend the employment agreement with Robert Johnson, PA, to provide clinic director services / Administration - Interim CEO Karen Cole said Robert Johnson, PA, has been working as the Interim Director of Clinic Services for one day each week; he has also worked in the Walk-In Clinic for the other four days each week. Robert has now agreed to accept the position of Director of Clinic Services full-time. The proposed agreement includes a proposed salary commensurate with a clinic administrator. CEO Cole said Robert would like to expand the hours in the Walk-In Clinic. This may entail hiring another full-time clinic provider, which would allow Robert to work part-time in the clinic. Board trustees unanimously approved the amended agreement with Robert Johnson as presented.

6. Hospital Administration / proposal to employ and enter into an employment agreement with David Masuck, M.D. to provide health care services / Administration - Interim CEO Karen Cole said Rural Family Medicine Residency physician David Masuck has signed a letter of intent to provide physician services at HGH following his graduation in June 2020. "He is excited to be able to remain in Winnemucca," said CEO Cole. Board trustees unanimously agreed with the proposal as presented.

Trustee Comments

Trustee Gene Hunt said the financial statements show that Quail Corner revenues are under budget due to poor utilization. He noted that if the hospital fills those empty beds, it will fix its financial issues at the same time.

Trustee Michelle Miller said she would be willing to help resolve some of admissions issues with Harmony Manor and Quail Corner.

Trustee Jennifer Hood expressed her condolences to the Salla family on the death of their father, Pete.

Trustee Bill Hammargren also expressed his condolences to the Salla family.

Next Meeting

The Humboldt County Hospital District Board of Trustees will meet next in special session at 5:30 p.m. Monday, March 4, in the HGH Sarah Winnemucca Conference Room. Meeting agendas, board minutes and more will be/are available at:

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