OSU Medical Trust Minutes

OSU Medical Authority and Trust

Thursday June 22, 2023 at 1:30 PM CDT
@ OSU Medical Center, 2nd Floor Administrative Boardroom, 744 W. 9th St., Tulsa

Agenda

Notice of the meeting was given in writing to the Oklahoma Secretary of State more than forty-eight (48) hours prior to the meeting, and the agenda of this meeting was posted at all entrances of Oklahoma State University Center for Health Sciences, 1111 West 17th Street; twenty-four (24) hours prior to such meeting, excluding Saturdays, Sundays, and legal holidays, in compliance with the Oklahoma Open Meeting Act.

Attendance

Present:
Members: Doug Evans, Johnny Stephens, Michael Herndon, Kevin Corbett Guest: Eric Atkinson, Damon Baker, Dennis Blankenship, Adam Bradley (Remote), Glenn Coffee, Melissa Cox, Deborah Dage, Finny Mathew, Lexie Norwood, Eric Polak, Bill Schloss, Jacey Smith, Chris Thurman, Erica Woolf
Absent:
Members: Jay Helm, Barry Steichen

1. Call to order and establishment of a quorum - Chair
   • Motion: The meeting was called to order by Trustee Johnny Stephens at 2:01 PM. After a roll call, Trustee Stephens declared that a quorum of the Trustees of the Oklahoma State University Medical Trust was present for the meeting.
2. Introduction/Seating of New Trustee Michael Herndon - Chair
   • Eric Polak welcomes Michael Herndon, D.O., newly-seated Trustee, to the Oklahoma State University Medical Trust Board of Trustees.
3. Discussion, consideration, and possible vote to approve the minutes from the April 26, 2023 meeting, and any amendments made thereto by Trustees - Chair - ACTION
   • File Name: Draft-OSU Medical Trust Minutes 4.26.2023.pdf
   • Motion: Motion to approve the minutes from the April 26, 2023 meeting.
   • Motion moved by Johnny Stephens and motion seconded by Kevin Corbett. Aye: Stephens, Corbett, Herndon, Evans Nay: None Abstain: None
4. Reserved Time for Comments from Elected Medical Staff Leadership (if requested) Chris Thurman, DO, Chief of Medical Staff
   • Dr. Thurman reported the relationship with staff, staff leadership, and faculty is healthy with good engagement.
5. CONTRACTUAL AGREEMENTS and EMPLOYMENT ACTIONS - Chair
   1. Discussion, consideration, and possible vote to appoint Michael Grow, DrPH, MBA, MT (ASCP), CIC, as Infection Prevention Manager - ACTION
      • ACHC requires that the hospital Infection Prevention Manager be appointed by the Board. A contract is in place until a candidate is identified to fill the position permanently.
      • File Name: HCT Candidate M.G., Interim Infection Prevention OSU 204271721514406.pdf
      • Finny Mathew informed the Board that Michael Grow is an interim candidate while we search for a permanent Infection Prevention Manager.
      • Motion: Motion to appoint Michael Grow, DrPH, MBA, MT (ASCP, CIC as Infection Prevention Manager.
      • Motion moved by Michael Herndon and motion seconded by Kevin Corbett. Aye: Herndon, Corbett, Evans, Stephens Nay: None Abstain: None
   2. Discussion, consideration and possible vote to approve a bulk buy purchase from GE for radiology equipment -Eric Atkinson, CFO - ACTION
      • File Name: SBAR GE Bulk Buy 2023.pdf
      • Eric Atkinson reported on a bulk buy from GE in order to receive five pieces of radiology equipment at a significantly discounted rate. One of the pieces of equipment aligns with the new mammography project that will be coming in FY24. Four of the items are budgeted in FY24 contingent upon Trust approval. The fifth piece of equipment will be included in the FY25 budget.
      • Motion: Motion to approve a bulk buy purchase from GE for radiology equipment.
      • Motion moved by Doug Evans and motion seconded by Michael Herndon. Aye: Evans, Herndon, Corbett, Stephens Nay: None Abstain: None
6. Discussion, consideration and possible vote to approve the expansion and renovation project at the Harvard Clinic - Melissa Cox - ACTION
   • File Name: OSU Harvard Expansion and Renovation.pdf
   • Melissa Cox reported on the need to upgrade the clinics in order to accommodate the new providers that are coming on board. The Harvard Clinic currently has around 5000 square feet with eight exam rooms; however, with how they are currently set up, it's meant for one provider. It was requested to add an additional 1100 square feet to the clinic. The volume will increase at the Harvard Clinics by adding additional space for more exams room, a lab, and additional provider nurse pods. There were five companies that came to look at the space, and three (Stava Building, Wiljo Interiors and Kleinco Construction) turned in a bid. Melissa is proposing that we use Wiljo Interiors for this project.
   • Motion: Motion to approve the expansion and renovation project at the Harvard Clinic contingent upon the approval of the fiscal year 2024 budget.
   • Motion moved by Michael Herndon and motion seconded by Doug Evans. Aye: Herndon, Evans, Stephens, Corbett Nay: None Abstain: None
7. FINANCE COMMITTEE - Doug Evans, Finance Committee Chairman
   1. Review of Month to Date and Year to Date May 2023 Financials
      • File Name: OSUMC May 2023 Presentation - Trust Meeting.pptx
      • Doug Evans discussed the month-to-date and year-to-date financials that were discussed in more detail in the Finance Committee Meeting.
   2. Discussion, consideration, and possible vote to approve the Fiscal Year 2024 OSU Medical Trust Operating and Capital Budgets - Eric Atkinson, CFO - ACTION
      • File Name: FY24 Budget OSUMC Finance Committee Presentation Final.pptx
      • Eric Atkinson presented a PowerPoint presentation of the budget that had been discussed in greater detail at the Finance Committee meeting which they endorsed the approval of.
        • Addition of new Primary Care Physicians at the Riverside and Harvard clinic.
        • Possible purchase of land in Collinsville, remodel at the Harvard Clinic and Riverside upgrade to the lab and flooring.
        • Addition of a 3D Mammography machine and associated testing/procedures.
        • Furnishing 5 East to be fully equipped in anticipation of a winter increase in admits/patient days.
        • Resident salary increase of 5% as discussed in Liaison Committee
        • Strategic Capital request that includes: the construction of a parking garage, an ARPA funded Research Lab with shell space for Medical Officer Space, and the addition of a new OR Suite, C-section suites in the OB Department and an ERP Conversion and Implementation.
      • Motion: Moved to approve the Fiscal Year 2024 OSU Medical Trust Operating and Capital Budget as recommended by the Finance Committee.
      • Motion moved by Kevin Corbett and motion seconded by Doug Evans. Aye: Corbett, Evans, Stephens, Herndon Nay: None Abstain: None
8. Recommendations of the Medical Executive Committee from its meeting on June 21, 2023 - Chris Thurman, DO, Chief of Staff
   1. Discussion, consideration, and possible vote to approve the Organized Medical Staff Renewal Appoint. and Credentials, Additional Privilege Requests, Temporary Privilege Request, Staff Status Changes and Resignations - ACTION
      • File Name: June 2023 -Credentials.pdf
      • Dr. Thurman reported on the June 2023 credentials. These were approved at Credentials Committee and MEC.
      • Motion: Moved to approve the Organized Medical Staff renewal, appointment and credentials, additional privilege request, staff changes and resignations.
      • Motion moved by Michael Herndon and motion seconded by Doug Evans. Aye: Herndon, Evans, Stephens, Corbett Nay: None Abstain: None
   2. Executive Committee of the Trust I May Credentials - Information Only
      • File Name: May 2023 -Executive Committee of the Trust Minutes .pdf
   3. Discussion, consideration, and possible approval of added, updated and retired performance improvement measures - ACTION
      • File Name: Gray Team Performance Improvement Presentation June 2023.pdf
      • File Name: Blue Team Performance Improvement Presentation May 2023.pdf
      • Dr. Damon Baker reported that there are several performance improvement measures that are being requested to be approved for retirement. Floors 6 East, 7 East, 8 East and 8 West are requesting to retire the Pl measure that aims to decrease CAUTI rates utilizing Foley removal protocols due to consistent compliance. Each of the units is requesting to add a new measure that aims to decrease CAUTI rates by maintaining greater than 90% compliance with the Foley bundle maintenance. All of these measures have been reviewed and approved by the Quality and Medical Executive Committee.
      • Motion: Moved to approve the added, updated, and retired performance improvement measures. Motion moved by Doug Evans and motion seconded by Michael Herndon.
   4. Discussion, consideration, and possible vote to approve new policies, policy amendments and retirement of policies - ACTION
      • File Name: Patient Safety Organization - PSO-Policy-Changes.pdf
      • Dr. Damon Baker recommended approving the Patient Safety Organization policy, which was approved by the Medical Executive Committee. Revisions to this policy were minimal, with updated title changes.
      • Motion: Moved to approve the amended PSO policy. Motion moved by Kevin Corbett and motion seconded by Michael Herndon.
   5. Information Only
      1. Safety Committee Meeting Minutes
         • File Name: SC Minutes 040523.pdf
         • File Name: SC Minutes 050323.pdf
      2. Quality Committee Meeting Minutes
         • File Name: Quality Council Meeting Minutes April 2023.pdf
         • File Name: Quality Council Meeting Minutes May 2023.pdf
      3. ACHC Post Survey Compliance Monitoring
         • File Name: ACHC Post Survey Compliance Monitoring Dashboard May 2023.pdf
         • File Name: ACHC Post Survey Compliance Monitoring Dashboard June 2023.pdf
         • Damon Baker asked the minutes to reflect the Board reviewed and accepted items VIII. E.
      4. CMS Response to EMTALA Survey on July 29, 2022 - Erica Woolf, Chief Nursing Officer
         • File Name: 370078.59249.NV.pdf
         • Erica Woolf reported on the EMTALA survey that took place on the July 29, 2022. Results from the survey show that the hospital is in compliance with EMTALA and the federal regulations listed in the letter.
9. Oklahoma State University Medical Center President's Update - Finny Mathew, MHA, President
   • File Name: President's Update.pdf
   • Finny Mathew gave an update on the hospital. Key highlights include:
     • The significant weather event in Tulsa came with some internal and external damage. The outside of the building had minor damages. The hospital received some computer damage due to the power surge. Everything is currently back up and functioning.
     • The hospital has a newly renovated auditorium that will provide a better experience for the residents and fellows.
     • New signs on the outside have changed the overall look of the hospital.
     • There has been Architect and Engineers on-site at the POB to provide a construction comparison on removing the POB versus keeping it. Evaluations and strategic comparisons have been done to decide the next steps for the POB.
     • The C-Section Suite had an unknown structural issue in the building that had caused a delay and further construction plans for designing around the building feature.
     • Family Fun Night at the Drillers Stadium was a success with a large turnout for our employees and their families.
10. OSUMC Professional Services LLC Manager Update - Bill Schloss, COO, OSU-CHS
    • File Name: OSU Medical Group June 2023.pdf
    • Bill Schloss gave an update on the PSLLC. Key highlights include:
      • FY23 Accomplishments include: The onboarding of Dr. Perry Evans in Cleveland OK and the WIB Pain Management group. PSLLC has also signed with Dr. Rachel Ray and Dr. Hallie Frederick.
      • After a decrease in volume in December and January due to the loss of providers, the clinics have increased their volume with the biggest months in March and May.
      • Part of the growth strategy for the PSLLC is with clinic renovations and leases of the Riverside and Harvard clinic.
11. Reports from Subsidiary Entities - Eric Polak, Chief Executive Officer, OSUMA&T
    • Eric Polak reported on the first on boarding training for the joint venture.
12. Unfinished Business - Chair
13. NEW BUSINESS (Limited to Matters Not Known About and Which Could Not Have Been Reasonably Foreseen Prior to Posting of the Agenda) Chair
14. ANNOUNCEMENTS (if any) Chair
    1. Next regularly scheduled Trust meeting: Thursday, July 27, 2023, at OSU-CHS, 1111 West 17th Street
15. EXECUTIVE SESSION Chair
    1. Discussion, consideration, and possible action to resolve into executive session pursuant to 25 O.S. S. 307(8)(4) to discuss investigation and possible litigation regarding former employee
    2. Discussion, consideration, and possible action to resolve into executive session pursuant to 25 O.S. S. 307(8)(4) to discuss risk management and other proprietary information
    3. Discussion, consideration, and possible action to resolve into executive session pursuant to 25 O.S. S. 307(8)(4) to discuss further review and training requirements on members of the credentialed medical staff
    4. Discussion, consideration, and possible action to reconvene to open session
16. Insurance Renewal
    1. Ratification of interim approval granted by the Chairman to execute the May 2023 Insurance Policy Changes and Renewal - ACTION
       • No vote due to loss of quorum.
    2. Discussion, consideration, and possible vote to approve the OSU Residents Medical Professional Insurance Renewal - ACTION
       
       • No vote due to loss of quorum.
         
17. ADJOURNMENT Chair
    
    • Meeting was adjourned at 3:57 PM.
      

Minutes signed off by Oklahoma State University Medical Trust Committee Chairman, Jay Helm.

If you would like a copy of these minutes, please reach out to Terri Tinkler at osuma@okstate.edu.