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September Board of Directors Meeting

September 27, 2016

Medical Staff: Dr. Acosta-Carlson, Chief Medical Officer

Dr. Acosta-Carlson reported things are busy, especially delivering babies, and going well.

Nursing Services: Nicole Thorell, Chief Nursing Officer

Nicole Thorell reported that LRHC is busy in Obstetrics. The nurses are really enjoying the new OB Central Monitoring and documentation because the system allows them to review and monitor all patients in one location without necessarily having to be in a patient's room.

Nursing also implemented a new online scheduling software
tool. This will help ensure the hospital is properly staffed, be aware of potential overtime, etc. It also gives staff a say in their schedule and provides a convenient way for staff to monitor their schedules. This system will eventually be implemented for staff in the Operating Room, Outpatient Clinic and at Family Medicine Specialists.

Service Excellence: Jim Hain, Chief Operating Officer

Jim Hain explained some reasons for patient satisfaction within the Obstetrics Department. Hain reminded the board that satisfaction is important, but the reason behind the satisfaction was equally important. Hain reported that OB patients were impressed with LRHC staff for being kind, caring, friendly and quick to respond. They also commented on the cleanliness of the rooms and the delicious food. Hain explained that these aspects of satisfaction are directly linked to LRHC practices, such as Patient Centered Care, AIDET and TeamStepps. These evidence-based practices and other processes, such as prenatal education and information, birthing plans and postnatal education answer why LRHC Obstetric patients are satisfied with their experience at LRHC.

Quality Update: Hawley Lister, Chief Quality Officer/Infection Control Coordinator

Hawley Lister reported that in August the Critical Access Hospital (CAH) review was completed. LRHC's sponsoring facility is and has been for several years, Bryan Health. This review looks at the facility's growth and quality over the past year.

LRHC was applauded on their participation in various state and national quality initiatives like core measures, Hospital Engagement Network and PQRS - all items that help LRHC maintain and strengthen quality care. Lister stated that the reviewer was also excited about the growth of services: the addition of Telemedicine, working with schools via the Athletic Trainer, and assessing the needs of the community in order to meet those needs.

This annual review helps LRHC establish goals to work on during the year. This year, LRHC will focus on antibiotic stewardship program development, improving health literacy and recruiting a Somalian Community Health Worker. Lister also stated that LRHC continues to refine the use of HealthDox, which will ensure the hospital is reviewing and updating policies and procedures in a timely manner.

Rob Anderson reported the CAH annual review was discussed in the Quality Subcommittee meeting and commented that HealthDox is an impressive document management system.

Leslie Marsh mentioned this was Hawley Lister's first year of leading the CAH annual review and she did a tremendous job!

Provider Recruitment: Leslie Marsh, Chief Executive Officer

Leslie Marsh reported that LRHC is currently pursuing two Primary Care providers with the ability to perform obstetric care.

Construction Report: Leslie Marsh, Chief Executive Officer

Leslie Marsh stated that LRHC is working on finalizing the punch list. She stated that the windows in the east and west entrances will need to be replaced. Aside from that, construction is down to final items.

Compliance Update: Dana Steiner, Executive Director of Patient Services

Dana Steiner reported that we are currently undergoing a Business Associates Agreement Audit to make sure that all vendor agreements are in place. She also reported that LRHC continues to wait on their visit from DNV.

Virtuous Organization Update: Jill Denker, Executive Director of Human Resources & Physician Liaison

Jill Denker reported that LRHC is continuing to work with Lee Elliot. Individual coaching continues to take place on a monthly basis. Denker reported that Elliot is currently working with individuals on Fulfillment. The next visit from Elliot will probably be sometime in January.

Leslie Marsh also shared that Denker will be sharing information about Lee Elliot's Virtuous Organization program and LRHC's experience in the program with Human Resources professionals at the Nebraska Hospital Association's meetings, the week of October 10th.

Marketing Update: Meredith O'Hanlon, Director of Marketing & Public Relations

Meredith O'Hanlon reported that the LRHC website has launched. She stated that she is currently welcoming feedback from the public to make the website as user-friendly as possible.

O'Hanlon also reported that LRHC would have its 40th Anniversary Celebration Thursday, October 27th from 5:30 - 7:30 pm at Lexington Regional Health Center's main lobby.

Strategic Planning: Leslie Marsh, Chief Executive Officer

Leslie Marsh reported that the National Healthcare environment is rapidly changing. MACRA & MIPS are new quality performance measurement tools that will be utilized in the upcoming years. Marsh said that our greatest challenge will be providing all services required and needed from our complex and diverse community. She stated that Kirsten Faessler, Director of Rehabilitation Services, and Pat Samway, Executive Director of Community and External Affairs, were working on the Community Health Needs Assessment, which is time consuming and a massive undertaking. This assessment will identify and define the target markets within our communities.

Financial Report: Wade Eschenbrenner, Chief Financial Officer

Wade Eschenbrenner reported on June 2016 finances and August 2016 finances. He stated that LRHC is currently preparing for an audit. Please see a comprehensive financial report in the link below.

Financial Report

New Business
No new business to report.

Old Business
No old business to report.

Public Comments
No public comments.