(direct access northeast entrance) AGENDA 1) CALL TO ORDER ...pagosaspringsmedicalcenter.org/wp-content/uploads/... · 8/27/2019 · 2017 initiatives. This saves our patients the

NOTICE OF REGULAR BOARD MEETING OF

THE UPPER SAN JUAN HEALTH SERVICE DISTRICT dba PAGOSA SPRINGS MEDICAL CENTER

Tuesday, August 27, 2019, at 5:30 PM

The Board Room (direct access – northeast entrance)

95 South Pagosa Blvd., Pagosa Springs, CO 81147

AGENDA

1) CALL TO ORDER; ADMINISTRATIVE MATTERS OF THE BOARD

a) Confirmation of quorum

b) Board member self-disclosure of actual, potential or perceived conflicts of interest

c) Approval of the Agenda (and changes, if any)

2) PUBLIC COMMENT (This is an opportunity for the public to make comment and/or address USJHSD

Board. Persons wishing to address the Board need to notify the Clerk to the Board, Heather Thomas, prior

to the start of the meeting. All public comments shall be limited to matters under the jurisdiction of the

Board and shall be expressly limited to three (3) minutes per person. The Board is not required to respond

to or discuss public comments. No action will be taken at this meeting on public comments.)

3) PRESENTATION: Orthopedic Service Line, Bill Webb, M.D.

4) REPORTS

a) Oral Reports (may be accompanied by a written report)

Chair Greg Schulte

Dir. Kate Alfred and Dir. Karin Daniels

Dir. Dr. Jim Pruitt and Dir. Karin Daniels

Chief Executive Officer, Dr. Rhonda Webb

i) Chair Report

ii) Contracts

iii) Strategic Planning

iv) CEO Report (‘18 Annual Review, Hospital)

v) Finance Report CFO, Chelle Keplinger and Treasurer, Dr. Campbell

b) Written Reports (no oral report unless the Board has questions)

COO-CNO, Kathee Douglas i) Operations Report

ii) Medical Staff Report Vice Chief of Staff, Dr. Corinne Reed

5) CONSENT AGENDA (The Consent Agenda is intended to allow Board approval, by a single motion, of

matters that are considered routine. There will be no separate discussion of Consent Agenda matters unless

requested.)

a) Approval of Board Member absences:

i) Regular meeting of 08/27/2019

b) Approval of Minutes for the following meeting(s):

i) Regular meeting of: 07/23/2019

c) Approval of Medical Staff report recommendations for new or renewal of provider privileges.

6) DECISION AGENDA

a) Consideration of proposed Resolution 2019-07, adjusting the meeting schedule in September and

October and affirming the days times that the Board will meet each month for the remainder of 2019.

7) EXECUTIVE SESSION

The Board reserves the right to meet in executive session for any other purpose allowed pursuant to C.R.S.

Section 24-6-402(4) and such topic is announced at open session of the meeting.

8) OTHER BUSINESS

9) ADJOURN

PAGOSA SPRINGS MEDICAL CENTER

Annual Program Evaluation

2018

ORAL REPORTS 4a.iv.

Annual Program Evaluation - 2018

2

INTRODUCTION

In compliance with Medicare’s Conditions of Participation for Critical Access Hospitals, Pagosa

Springs Medical Center (PSMC) evaluates its total program of services each year. We review

the appropriateness of the utilization of services from a medical necessity standpoint, the quality

and efficiency of our services and the satisfaction of the patients we serve.

Because we strive to provide the highest quality healthcare that is easily accessible to our rural

population, we review trends in demographics, referral patterns and the input from our

community when evaluating our program.

Using patient comments, community meetings and surveys, we evaluate the satisfaction of the

community with our service, facility and overall environment of care.

A robust peer review program provides assurance that our medical services are of the highest

quality, with any issues identified and addressed promptly. Review of quality measures,

performance improvement activities and policies and procedures allows use to make process

changes that are necessary to support excellence in clinical practice.

The results of this evaluation are provided to leadership and the Board of Directors as a tool for

strategic planning.

SCOPE OF SERVICES

Pagosa Springs Medical Center is fully licensed and accredited as a Critical Access Hospital. It

has eleven acute care/swing beds and seven Emergency Department beds. It is a designated

Level Four Trauma Center.

Clinical Diagnostic/Treatment Services

Anesthesia Services

o General and local anesthesia

o OP pain management

o IP pain management

Cardiopulmonary Services

o Respiratory Therapy

o EKG

o Event Monitoring

o Stress Testing

o Echocardiography

o Basic Pulmonary Function Testing

Case Management/Discharge Planning

Diagnostic Imaging

o General Radiology

o Bone Densitometry

o Ultrasound

o CT

o MRI

o Mammography

ORAL REPORTS 4a.iv.


3

Dietary

o Dietitian Consultation (by contract)

Emergency Medical Services (Ambulance)

o EMS Training Center

ACLS, PALS, TNCC, BLS certification

Community Outreach

AED

CPR

Stop the Bleed

EMT-B certification

Emergency Department

o Trauma Services – Level 4 certification

o Tele-neurology (by contract)

o Tele-psychiatry (by contract)

Infusion Therapy

o Therapeutic Phlebotomy

o Oncology Infusions

o IV Hydration

o Medication Administration

Inpatient/Observation Services

o Adult and Pediatric Medical/Surgical

Subject to extenuating circumstances (e.g., transfers precluded due to

inclement weather), Pagosa Springs Medical Center does not admit

pediatric patients who weigh less than 10 kilograms (22 pounds).

Laboratory Services

o Blood Bank

o General Laboratory Services

o Pathology (by contract)

Oncology

o Provider clinic

o Chemotherapy injection, infusion, and/ or irrigation

o Genetic Counseling

o Patient Navigation

o Survivorship

Pharmacy

o IP pharmacy only

o Participates in 340B program

Rehabilitative Services

o Swing Bed

o Physical Therapy (Inpatient and Outpatient)

Surgical Services

o General Surgery

o Orthopedic Surgery

o Gastroenterology

o Ophthalmological Surgery

o Ear, Nose and Throat Surgery

ORAL REPORTS 4a.iv.


4

o Gynecological Surgery

o Pain Management Services

Support Services:

Administration

Compliance

Credentialing/Medical Staff Office

Employee Health

Environmental Services

Financial Accounting

Health Information Management

Human Resources

Informatics

Information Technology

Marketing and Communication

Materials Management

Patient Financial Services

Patient Registration and Pre-service

Plant Operations and Life Safety

Quality and Patient Safety

Risk Management and Legal

Community Services:

Community Education

Patient and Family Information and Education

2018 PROGRAM EVALUATION

Sources of Data

PSMC used the following sources of data for the 2018 program evaluation:

Concurrent Case Management

Quality Council Minutes

Performance Improvement Committee Minutes

Occurrence Reports

Patient Satisfaction Surveys (HCAPHS)

Community Feedback

Demographic and Economic Profiles

Hospital Generated Statistical Reports

Statistics Generated by Outside Agencies

Evaluation of 2017 Initiatives

Trends in Health Care Demographics

The 2019 County Health Rankings published by the state of Colorado indicates that Archuleta

County’s population continues to grow at approximately 0.3% per year and in 2017 was 13,316.

ORAL REPORTS 4a.iv.


5

The age demographic for Archuleta County is unique in that over 25% of the population is

greater than 65 years old. Only 16.7% of the population statewide is over 65.

Archuleta County continues to have a substantial number of residents living at or below the

poverty level, approximately 20%. The median income is just over $50,000 compared to the

statewide median income of $64,000. Approximately 14% of the population in Archuleta

County is uninsured.

Colorado Department of Public Health data shows that 77.8% of residents have a personal

doctor, which is better than the State at 74.8%. The ratio of patients to primary care doctors is

1,170:1, again better than the State ratio which is 1,230:1. Access to mental health providers is

limited with the ratio of patients to providers being 830:1 compared to the State at 300:1.

County Health Rankings for Colorado counties puts Archuleta County at 27 out 60 in the Health

Factors Category and at 13 out of 60 for the Health Outcomes category for 2019. Health Factors

include Education, Employment, Family and Social Support and Community Safety. Health

Outcomes include Tobacco Use, Diet and Exercise, Alcohol and Drug Use, Sexual Activity,

Access to Care and Quality of Care.

PSMC Hospital Generated Statistics

Item 2017 2018 Change

Emergency Department visits 8017 6671

Inpatient Days 1267 1190

Length of Stay 3.0 2.6

Clinic Visits 21906 24603

Specialist Visits 3366 4957

Behavioral Health Visits 1285 1509

Walk-in Clinic Visits 663 5604

Mammography Procedures 920 865

MRI Procedures 884 1076

Ultrasound Procedures 1086 1137

General Radiology Procedures 7795 7511

CT Scans 2761 3437

Gastrointestinal Procedures 486 451

General Surgery Procedures 121 124

Orthopedic Surgery Procedures 328 334

ENT Surgery Procedures 0 9

Eye Surgery Procedures 6 20

Pain Management Procedures 68 97

Infusion Therapy Procedures 987 1763

Laboratory Tests 18942 19656

ORAL REPORTS 4a.iv.


6

Community Input

In March of 2019, PSMC held a Community Partners Meeting to solicit input from other health

care providers and the public on gaps in medical services in the county. Approximately 40

persons attended and we gained valuable insight on the “state of health care” in Archuleta

County. Several gaps in care were identified including the availability of mental health services,

treatment options for substance use disorders and specialty care for complex chronic conditions.

Evaluation of Our 2017 Initiatives

We mention first two RHC-based initiatives from 2017 in this report of 2018 because they had a

direct impact on the utilization of the Emergency Department (ED). In 2018, the number of ED

visits fell by almost 17%. We consider this to be a reflection of care that was previously

delivered in the ED now being more appropriately delivered in the RHC setting as a result of the

2017 initiatives. This saves our patients the cost of a much more expensive ED visit.

Expansion of clinic hours – PSMC expanded the hours of its Rural Health Clinic (RHC) by

adding early morning appointments with limited success. These appointments were frequently

unfilled and we have since limited the availability of early morning appointments.

Availability of walk in visits –Increasing the availability of walk-in visits to PSMC’s Rural

Health Clinic has been very successful in increasing patient access to primary care and reducing

utilization of the emergency department for situations that are more appropriately handled in a

clinic setting. There were 663 visits in 2017 and 5,604 in 2018.

Combining of the Primary Care and Specialty Clinics – We successfully integrated the

primary care and specialty clinics under the Rural Health Clinic umbrella, improving patient

satisfaction, maximizing staff efficiency and improving the referral process.

Added a part-time Cardiologist – Cardiology visits continue to grow. The number of visits

doubled in 2018 to 474.

Added Ophthalmological Surgery – Service continues to grow with a 233% increase from

2017.

Infusion Therapy - PSMC continues to experience significant growth in this department.

Service 2017 2018 Change

Blood Transfusion 36 48

IM Injection 14 44

IV Hydration 15 39

IV Infusion 418 654

IVIG 12 56

Portacath Flush 27 97

SQ Injection 25 193

ORAL REPORTS 4a.iv.


7

Evaluation of 2018 Initiatives

Renovation of Surgical Services - Renovation plans included upgrading the Procedure Room to

an Operating Suite and upgrading PSMC’s HVAC system. PSMC’s HVAC is inadequate to

support the increased demand of surgery and oncology services. In 2018, PSMC applied for and

received a grant from Colorado’s Department of Local Affairs (DOLA) of $910,000 toward the

HVAC project. In 2019, PSMC anticipates completing final plans and pricing for the project.

The HVAC project construction is currently planned for 2020.

Revenue Optimization for Surgical Services and Supply Chain – PSMC undertook a joint

project with Cerner to optimize charge capture and streamline complex processes for Surgical

Services. We have just now completed this transition and do not yet have data to evaluate its

success.

Charge Master Revision – PSMC enlisted Cerner’s help with a complete revision of the Charge

Description Master in order to improve our clean claims rate, reduce denials, reduce manual

interventions by billing staff and optimize charge capture. We are still collecting data to evaluate

the success of this project.

The Center for Cancer and Blood Disorders (new service line in January 2018)

Service 2017 2018 Change

Chemo SQ NA 6

Chemo Infusion NA 134

Chemo IV push NA 17

Chemo IM NA 17

Peripheral Lab Draw NA 87

Therapeutic Phlebotomy 168 341

Oncology Clinic Visits NA 535

The Oncology Business Plan completed in 2017 estimated expected patient volumes and

revenues. PSMC projected unique patient volume at 100 for 2018; we exceeded that volume

expectation with 175 unique patients. The Oncology Business Plan projected 4.4 million in

revenues from drugs, professional fees, and infusion services. Actual revenues for 2018 were 2.4

million. However, PSMC identified a miscalculated assumption in the original Oncology

Business Plan for professional fees of about 1 million, leaving PSMC about1 million short of the

corrected projected revenues.

Expanded participation in the Pharmacy 340B program – Positive financial benefit of

$626,056.45.

Therapeutic Phlebotomy 168 341

Not Classified 272 30

ORAL REPORTS 4a.iv.


8

Outpatient Physical therapy services (new service line in 2018) – We added capability for

outpatient visits to provide bridge services due to prolonged wait times for access to local

physical therapy providers.

Outpatient Physical Therapy visits for PSMC employees (new service line in 2018) – We

added capability for outpatient visits for our employees to mitigate prolonged wait times for

access to local physical therapy providers.

Speech Therapy (new service line in 2018) – We added a part-time speech therapist to meet

inpatient needs.

Hired a new CFO – Successfully recruited and hired replacement for retiring CFO.

2018 Quality and Performance Improvement Activities

Emergency Preparedness -

The organization has made significant progress / improvements in the area of Emergency

Preparedness.

Policy/procedure and staff training for Active Shooter was completed in February 2018.

All emergency preparedness policies and procedures were reviewed and revised. We

added required policy and procedures for Code Brown (Winter Storm), Code White

(Hospital Evacuation), Code Orange (Hazardous Spill), Code Purple (Pandemic, Possible

Exposure to Serious Infection), Code Pink (Infant Abduction), Code Silver (Active

Shooter), and Code Dr. Mary Fisher (Combative Person).

PSMC activated our Emergency Operations Plan eight times in 2018. PSMC activated

for:

o Code Green - Generator Outage on 1/20/18

o Code Green - Gas Leak in the Kitchen 2/10/18

o Code Green - Phone Outage on 10/10/18

o Code Green - Phone Outage on 11/8/18

o Code Green - Phone Outage 12/8/18

o Code Black - 12/13/18

o Code Brown – 12/27/18

o Code Green - Capacity 12/28/18

PSMC participated in a tabletop Internet Failure Exercise on 1/31/2018 sponsored by

Mike Hill, HCISPP from Cerner and a Southwest Colorado Healthcare Coalition

Capacity Surge Test on 10/18/2018.

Required Quality Reporting -

Quality Payment Program / Merit-Based Incentive Payment System (MIPS): PSMC

completed PY 2018 submission, achieving a final score of 100 out of 100

points. Performance resulted in a positive payment adjustment of 1.68% for the 2020-

billing year.

ORAL REPORTS 4a.iv.


9

Eligible Hospital (EH) Promoting Interoperability: PSMC completed PY 2018

submission, including the EH eCQM requirement.

Eligible Provider (EP) Medicaid Meaningful Use: PSMC completed PY 2018

submission for one provider, including the EP eCQM requirement. No other providers

met the 30% Medicaid encounter requirement.

Medicare Beneficiary Quality Improvement Program: PSMC completed submission for

Q4 2018 Outpatient Quality Reporting measures including AMI, CP and ED. This allows

us access to $12,000 for HCAPHS services and consulting services through the SHIP

Grant.

Hospital Quality Improvement Program (HQIP): The hospital submitted all required

documentation and received a Supplemental Payment of $323,241.

Electronic Health Record/Informatics – The informatics department provided support for

multiple improvement projects including:

Revenue Cycle optimization

Charge Master Revision

Surgical Services and Supply Chain Optimization

Dragon Medical One conversion

Transition to DynamicDoc

Attaining HIMMS level 7

Patient Safety Activities

Achieved HIMMS Level 7 in March 2018. PSMC is the smallest independent hospital to

achieve Stage 7 recognition, a designation only 6.5% of US hospitals have achieved.

HIMMS levels represent the progressive utilization of the electronic health record to

promote patient safety.

Successfully completed a comprehensive Patient Safety and Risk Management

Assessment by our malpractice carrier. Only one recommendation resulted from that

survey.

Patient Satisfaction Efforts

Conducted daily rounding on 100% of inpatient population, allowing for immediate

service recovery when appropriate.

Provided immediate service recovery for on-site patient complaints by having the Quality

Manager interact with patients at the time of the complaint.

Used the Clarity Event reporting system to track to resolution all patient complaints

Information Technology

Participated in achieving HIMSS Analytics Level 7 Designation

Began preparations for Enterprise-wide Windows 10 Hardware refresh

Began preparations for migration from Server 2008R2 to Server 2016

Completed 3rd Party Audit of Information Technology Environment to audit performance

of outsourced IT Management Company

Following results of the 3rd Party Audit – hired IT Manager to start the transition away

from outsourced IT Management to re-appropriate IT Operations internally at PSMC.

ORAL REPORTS 4a.iv.


10

Peer Review Program

PSMC has established a comprehensive peer review program to insure the quality and

appropriateness of medical services. Results of peer review are reported to the Peer Review

Committee where findings are discussed and actions recommended. Peer review results are

considered in the appointment process. The table below lists the components of the medical peer

review program.

Provider Peer Review Triggers List

Clinic

Clinic Random Peer Review (goal of 2% or minimum of 10/yr.)

Specialty Clinic Random (goal of 2% or minimum of 10/yr.)

ED Reviews

ED Random Peer Review (goal of 2%-only required if 2% not met by other ED

triggers below)

All obstetrical and newborn cases

ED Transfer out (transferred out via flight only)

ED AMA

ED Deaths

Inpatient Reviews

Inpatient Random Peer Reviews (goal of 2% or minimum of 10/yr.)

All inpatient re-admissions for same diagnosis w/I 30 days

All inpatient with LOS > 7 days

All inpatient stays ≤ 24 hours

All transfers from IP to another facility

IP Deaths (unexpected only)

All hospital acquired Infections

Surgery Random Peer Reviews

Random Surgery Reviews (goal of 2% or minimum of 10/yr.)

All post-op surgical infections

Unplanned return to OR

Unplanned ED visit within 24 hours after an OR procedure

Anastomotic Leaks

GI lab Perforation

Unanticipated Need for Transfusion

Post Op DVT

Unexpected OR Outcomes

Malignant Hyperthermia/adverse reaction to anesthesia/anaphylactic shock or IV

conscious sedation complications

CRNA Random Peer Reviews (goal of 2% or minimum of 10/yr.)

General Standing Peer Reviews

All hemolytic transfusion reactions

ORAL REPORTS 4a.iv.


11

All requested from providers, administration, nursing, risk management, and

quality

All mortality cases (unexpected IP, all OP, ED, OR)

Medical Staff Additions

LAST NAME FIRST NAME PRACTICE AREA GROUP NAME

Alonso-Jeckell Yaima Telepsychiatry MindCare Solutions/Health ONE

Virtual Network

Armentano Stephanie Licensed Clinical

Social Worker

Axis Health System

Bentley William Neurology Pagosa Springs Medical Center /

Colorado Permanente Medical Group

Bidart Chad Cardiology /

Telecardiology

Mercy Cardiology Associates

Bishop John Surgery Pagosa Springs Medical Center /

Gunnison Valley Hospital

Borden Kelly Teleradiology Radiology Imaging Associates

Bryant Kevin "KD" Licensed Professional

Counselor

Axis Health System

Cesary Kelly Oncology &

Hematology

Pagosa Springs Medical Center

Crete Ryan Teleradiology Radiology Imaging Associates

DeNault Michelle Telepsychiatry MindCare Solutions/HealthONE

Virtual Network

Denier Jamie Licensed Social

Worker

Axis Health System

Dickerson Elliot Teleradiology Radiology Imaging Associates

Farmer Tracy Licensed Clinic Social

Worker

Axis Health System

Fidai Gulzar Hospitalist Pagosa Springs Medical Center

Fisher Kerry Oncology &

Hematology


Foster Bridget Licensed Clinical

Social Worker

Axis Health System

Fuller Samuel Teleradiology Radiology Imaging Associates

Golden Louis Teleradiology Radiology Imaging Associates

Harlan Josiah Licensed Professional

Counselor

Axis Health System

Hill Jason Teleneurology Blue Sky Neurology/HealthONE

Virtual Network

ORAL REPORTS 4a.iv.


12

Hosey Anne Licensed Professional

Counselor Candidate

Axis Health System

Jackson Grace Telepsychiatry MindCare Solutions/Health ONE

Virtual Network

Jordan William Oncology &

Hematology


Kelly Kevin Psychology Pagosa Springs Medical Center

Lampe Emily Teleneurology Blue Sky Neurology/HealthONE

Virtual Network

McCarthy Paul Pathology Pueblo Pathology Group

Messina Taylor Licensed Professional

Counselor

Axis Health System

Newman Suzanne Telepsychiatry MindCare Solutions/HealthONE

Virtual Network

Newsome Calvin Family Medicine &

Neurology,

Gastroenterology,

Cardiology, ENT

Support


Primary Care Clinic

Norwood William Surgery Norwood Surgical Specialists / Pagosa

Springs Medical Center

Palusinski Robert Cardiology /

Telecardiology

Mercy Cardiology Associates

Parrisbalogun Stefani Telepsychiatry MindCare Solutions/HealthONE

Virtual Network

Patel Nishant Teleradiology Radiology Imaging Associates

Phelps Dennis Orthopedics Pagosa Springs Medical Center / UC

Health Orthopedics

Potts Scot Pathology Pueblo Pathology Group

Reuter Gregory Teleradiology Radiology Imaging Associates

Richards John Teleradiology Radiology Imaging Associates

Ropp Benjamin Pathology Pueblo Pathology Group

Sanchez Linda Licensed Professional

Counselor

Axis Health System

Splichal Aron Teleradiology Radiology Imaging Associates

Stahl Cosette Teleradiology Radiology Imaging Associates

Tjan Virginia Oncology &

Hematology


Voigts Kerri Emergency Medicine Pagosa Springs Medical Center

ORAL REPORTS 4a.iv.


13

Policy and Procedure Review

Pagosa Springs Medical Center utilizes a cloud-based software system for the management of

policies and procedures. At the beginning of 2018, there were 1762 policies, procedures and

contracts under management. The annual review and revision of documents is fully automated,

with reviewers receiving notification that they have documents to review via email each week.

There is a custom approval process for each document consisting of between four and six

reviewers including a member of leadership.

In addition to the mandatory annual review, documents are available for revision whenever

necessary and proceed through the entire approval process for each revision.

Staff members are assigned to read all policies and procedures that are relevant to their position.

Completion of assignments is monitored and department managers are responsible for staff

compliance.

Staff has immediate access to all relevant documents and are required to read and sign off on all

documents related to their job role.

2019 Planned Initiatives

Improving Cash on Hand -

At the end of 2018, PSMC had 53 days cash on hand. PSMC’s planned initiatives for 2019 to

improve cash on hand include reducing expense, improving collection of revenues, and some

management and planning activities aimed to increase cash. With respect to reducing expense,

PSMC will (as possible) do the following: reduce the number of employees and contractors

through attrition; terminate use of off-site leased space; and amend service agreements to reduce

expense. With respect to improving collection of revenues, PSMC will do the following:

outsource billing of out-of-state Medicaid, motor vehicles and worker comp claims; outsource

coding to improve accuracy; implement processes to decrease denials related to preauthorization

and medical necessity; and implement processes to improve timely filing of clean claims to

decrease denials. With respect to management and planning, PSMC will do the following:

operationalize offering swing bed services for orthopedic patients; evaluate and develop a plan to

improve outpatient clinic productivity; evaluate and develop a plan to decrease PSMC’s cost to

PSMC for employee health insurance coverage; evaluate and develop a plan to reduce the cost

of the MRI lease; evaluate and develop a plan for more efficient IT/phone support; and evaluate

the feasibility of expanding pain management services.

Hospital Transformation Program -

In the fall of 2018, the Colorado Department of Health Care Policy and Financing (HCPF) began

a statewide initiative designed to change how health care is provided to Medicaid beneficiaries.

The program requires hospitals to develop relationships with community partners, develop

initiatives that improve care and cut costs. HCPF has developed a package of indicators that will

be used to measure the hospitals performance. At stake is a portion of the hospitals supplemental

payment each year. This is a huge undertaking for a small CAH, but crucial for moving to value

based payments.

PSMC has committed a key group of personnel to this five-year project.

ORAL REPORTS 4a.iv.


14

Possible programs related to this project are:

Hospital Social Services;

Clinic Social Services;

Chronic Disease Management;

Expanded Behavioral Health Services;

Zero Suicide Initiatives;

Depression Screening / Suicide Risk Assessment for all patients;

Increasing partnerships with area agencies to reduce patient barriers to achieving health

and wellness.

HVAC Renovation -

Planned renovation of hospital HVAC system tentatively scheduled for April 2020 to include:

Procedure Room renovation as OR suite;

RTU 2 upgrade to meet Surgical Services demand;

Control systems related HVAC system function and monitoring capabilities;

VAV replacement to improve current HVAC function as well as save energy;

Revision of Pharmacy negative pressure rooms to meet new standards.

Planning for the renovation will occur throughout 2019.

Improve Access to Care -

Revise scheduling protocols to increase outpatient appointment availability.

Continue to improve access to providers by expanding hours of service.

Add additional neurology services to augment a neurologist who plans to retire.

Explore telemedicine for Psychiatry and other specialties.

ORAL REPORTS 4a.iv.

USJHSD Finance Report USJHSD Board Packet, 08-27-2019

Page 1 of 1

Finance Committee & CFO Report,

USJHSD Board Meeting on August 27, 2019

This report provides highlights of PSMC’s July financials and the discussions of the Board’s Finance

Committee that met on August 20, 2019.

1) July Bottom Line: PSMC had an all-time record for gross charges in July of just over $6.3MM, which

exceeded budget. Due to charity care, bad debt and contractual deductions of payers (e.g., Medicare,

Medicaid and commercial insurers), PSMC, is generally paid approximately fifty percent of gross

charges. Hospitals are always expensive to operate but PSMC continued to hold down its expenses,

which contributed to PSMC finishing the month of July with a total net gain of $545,977. PSMC’s

total net revenues year-to-date of are $580,971, which is less than budget but slightly exceeds 2018

YTD. Like most businesses in Pagosa Springs, PSMC’s net revenues are lower for the first half of the

year and increase during the summer. PSMC budgeted a strong July and we congratulate our staff for

meeting patient demands and helping so many.

2) Revenues: Inpatient and outpatient revenues were strong in July. Inpatient Surgery and Imaging were

the only departments that did not hit their budgeted revenue.

3) Deductions to Gross Revenues for Payer Contractuals, Charity and Bad Debt: Each month PSMC

has deductions to its revenue for bad debt, charity care as well as deductions made by third-party payers

(Medicare and commercial insurers) that are referred to as payer contractuals. Deductions for the

month of July were 4% below budget, which helped result in July’s positive bottom line. Year to date,

PSMC’s charity care and contractual deductions by payers has greatly exceeded budget resulting in a

little more than 1 million greater deductions to PSMC revenue than budgeted.

4) Expenses: PSMC continued to do a good job holding down expenses, and we were 6% under budget

for the month of July (this is nearly $200,000 under budget for the month). Year-to-date, expenses

continue to be under budget by 2% (which is nearly $500,000).

5) Cash and collections:

a) PSMC increased operating cash in July to $5.1MM from $4.5 MM in June 2019.

b) Patient collections were $2.7 MM for the month, 375K more than forecasted. The patients from

PSMC are starting to utilize our payment portal more and we are glad to report that 110 patients

used it to pay their balance in full or to set up a payment plan in July.

c) As of the end of July, PSMC is at 62 days of gross A/R; however, PSMC’s gross accounts

receivable balance increased $180K to $11.24 MM. We continue diligently working the A/R and

are hitting some targets that we not did expect to hit until December.

6) Progress Report Re Consultant’s Recommendations to Increase Days of Cash: PSMC

presented and discussed in depth with the Finance Committee the status of progress on the

consultant’s recommendations. Per direction of the Board, until the goals are met,, staff will

provide the Board with a written monthly report and an oral report quarterly (in May,

August, & November).

ORAL REPORTS 4a.v.

FINANCIAL PRESENTATION

YTD JULY 2019

ORAL REPORTS 4a.v.

1

GROSS REVENUE

0

7,500,000

15,000,000

22,500,000

30,000,000

37,500,000

45,000,000

YTD

35,026,226 34,318,16732,871,109

Actual Budget Prior Year

- 2,000,000 4,000,000 6,000,000 8,000,000

10,000,000

July

6,309,053 5,576,680 5,466,348

Budget Prior Year

732,373

13.13%

842,705

15.42%

708,059

2.06%2,155,117

6.56%

Actual

GROSS REVENUE

$3,300,000

$3,600,000

$3,900,000

$4,200,000

$4,500,000

$4,800,000

$5,100,000

$5,400,000

$5,700,000

$6,000,000

$6,300,000

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

FY 2019 FY 2018 FY 2017 FY 2016

ORAL REPORTS 4a.v.

2

NET PATIENT REVENUE

04,000,0008,000,000

12,000,00016,000,00020,000,00024,000,00028,000,00032,000,00036,000,00040,000,000

YTD

18,380,406 19,433,639

18,010,502

- 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 6,000,000

July

3,009,707 3,125,538 3,213,107

Prior Year

-115,831

-3.71%

-203,400

-6.33%

-1,053,233

-5.42%

369,904

2.05%

Actual Budget


NET REVENUE

$1,000,000

$1,250,000

$1,500,000

$1,750,000

$2,000,000

$2,250,000

$2,500,000

$2,750,000

$3,000,000

$3,250,000

$3,500,000

$3,750,000

$4,000,000

$4,250,000

$4,500,000


FY 2019 FY 2018 FY 2017 FY 2016

ORAL REPORTS 4a.v.

3

EXPENSES

04,000,0008,000,000

12,000,00016,000,00020,000,00024,000,00028,000,00032,000,000

YTD

20,485,173 20,966,063 20,252,021

- 750,000

1,500,000 2,250,000 3,000,000 3,750,000 4,500,000

July

2,867,179 3,060,981 3,037,247

-193,802

-6.33%

-170,068

-5.60%

-480,890

-2.29%

233,152

1.15%



EXPENSES

$-

$250,000

$500,000

$750,000

$1,000,000

$1,250,000

$1,500,000

$1,750,000

$2,000,000

$2,250,000

$2,500,000

$2,750,000

$3,000,000

$3,250,000

$3,500,000

$3,750,000

$4,000,000


FY 2019 FY 2018 FY 2017 FY 2016

ORAL REPORTS 4a.v.

4

NET INCOME

(1,000,000) -

1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 7,000,000

YTD

580,971

1,564,876

574,600

- 500,000

1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000

July

545,977 585,074 557,193

-983,905

-62.87%

6,371

1.11%



NET INCOME

$(600,000)

$(350,000)

$(100,000)

$150,000

$400,000

$650,000

$900,000

$1,150,000

$1,400,000

$1,650,000

$1,900,000

$2,150,000

$2,400,000

$2,650,000

$2,900,000

$3,150,000


FY 2019 FY 2018 FY 2017 FY 2016 FY 2015

ORAL REPORTS 4a.v.

5

DAYS IN ACCOUNTS

RECEIVABLE

0

10

20

30

40

50

60

70

80

90

100

Jun-18 Aug-18 Oct-18 Dec-18 Feb-19 Apr-19 Jun-19

71.9 72.2 70.2 69.4 70.1 70.5 76.6 76.5 76.3

78.4

69.9 68.6 69.6

61.4 60.0 58.0 53.0 54.0 54.0 53.0

61.0 57.0

62.0 65.0

53.0 49.0

54.0 53.0

Gross Net

DAYS CASH ON HAND

0

10

20

30

40

50

60

70

80

90

100

Jan-18 Apr-18 Jul-18 Oct-18 Jan-19 Apr-19 Jul-19

48.6 49.4

44.3 45.1 40.7

33.9

43.0 38.8 40.2

43.2 48.9

52.4

38.3 41.2

36.4

47.4 50.3

39.3

46.1

ORAL REPORTS 4a.v.

6

CASH COLLECTIONS

$-

$250,000

$500,000

$750,000

$1,000,000

$1,250,000

$1,500,000

$1,750,000

$2,000,000

$2,250,000

$2,500,000

$2,750,000

$3,000,000

$3,250,000

$3,500,000

$3,750,000

$4,000,000


FY 2019 FY 2018 FY 2017

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ORAL REPORTS 4a.v.

ACTION DEADLINE MAY JUNE JULY AUG. SEPT OCT NOV

REDUCE EXPENSE

From 12/31/18 level staffing, reduce FTEs and contractors (as practical and through attrition, if possible). ongoing 10 positions 10 positions 10 positions 9 positions

As possible, restructure positions to reduce expense. ongoing 4 positions 4 positions 5 positions 5 positions

Create and implement a plan to terminate lease for use of off-site space. 6/30/2019 75% 95% 100% 100%

Amend/change service agreements to reduce expense. ongoing 40% 44% 55% 55%

Subject to challenges with hiring, replace 2 emergency room night-shift RNs with paramedics. 5/31/2019 0% 0% 0% 100%

IMPROVE REVENUES COLLECTED

Outsource billing for out-of-state Medicaid, motor vehicles and worker comp claims. 3/1/2019 100% 100% 100% 100%

Contract with a third party for coding to improve accuracy. 2/1/2019 100% 100% 100% 100%

Develop and implement process for collecting coinsurance for patients. 7/31/2019 100% 100% 100% 90%

Implement coding software to enable PSMC to compute payments on Medicaid EAPGs to assure accuracy of payment. 10/31/2019 10% 10% 20% 30%

From 12/31/18 levels, develop and implement processes that should decrease denials by 50% (denials related to pre-

authorization, medical necessity and otherwise).10/31/2019 25% 30% 30% 50%

From 12/31/18 levels, implement process to improve timely filing of clean claims to decrease denials by 50%. 9/30/2019 100% 100% 100% 100%

Develop and implement a plan to reduce gross days of A/R to 68 (from 12/31/18 level of 76.6 gross days of A/R). 7/31/2019 88% 93% 81.16% 100% (61.43)

Engage contractors if 68 days not achieved on 7/31/19 9/30/2019 n/a n/a n/a n/a

Develop and implement a plan to reduce gross days of A/R to 62 (from 12/31/18 level of 76.6 gross days of A/R). 12/31/2019 52% 54.70% 47.80% 100%

Create and implement a career matrix program for billing office to reduce turnover and enhance stability of collections. 1/31/2019 100% 100% 100% 100%

If matrix does not produce improvement, evaluate alternatives. 1/1/2020 n/a n/a n/a n/a

MANAGEMENT AND PLANNING

Operationalize offering swing bed services for orthopedic patients pending hiring of appropriate staff. 8/31/2019 80% 100% 100% 100%

Develop a monthly cash forecast to allow management to predict progress relative to the cash goal and measure days of cash. 6/30/2019 0% 100% 100% 100%

Compute Medicare productivity for the RHC monthly. 6/30/2019 10% 100% 100% 100%

Evaluate and develop/implement a plan to address time allotted in the RHC for patient visits and improve Medicare

productivity in the RHC.10/31/2019 10% 10% 20% 75%

Evaluation and develop/implement a plan to decrease PSMC’s expense for employee health insurance benefit for employee’s

spouse and children.7/1/2019 75% 100% 100% 100%

Evaluate and develop/implement a plan to reduce ongoing expense for MRI. 12/31/2019 0% 0% 0% 0%

Evaluate and develop a plan for efficient IT/Phone support at a lower cost (current contract for support does not end until

12/31/2020).12/31/2019 25% 50% 80% 100%

Evaluate and develop/implement a plan to reduce professional hours in Oncology program to better address current and

projected demand.12/31/2019 20% 20% 100% 100%

Evaluate the feasibility of providing physical therapy services for all outpatients. 10/31/2019 0% 0% 0% 20%

Evaluate the feasibility of refinancing the 2006/2007 bonds. 12/31/2019 0% 0% 10% 100%

Evaluate the feasibility of increasing veteran use of the RHC. 12/31/2019 0% 0% 10% 100%

Evaluate the feasibility of expanding pain management services. 12/31/2019 0% 20% 20% 75%

USJHSD Management Progress Reporting Tool USJHSD Board Packet, 08-27-2019

Page 1 of 1

ORAL REPORTS 4a.v.

TO: Board of Directors of PSMC/USJHSD RE: Evaluation of for refinancing the 2006 bonds DATE: 8/23/19

The consultant’s report requires that PSMC evaluate the feasibility of refinancing the 2006/2007 bonds (note: the 2007 bonds have been fully paid). As part of evaluation, PSMC worked with David Lucas of Sherman & Howard (attorney who works solely in bonds and has helped PSMC in the past) and Jason Simmons of Hilltop Securities, Inc. (specializes in evaluation and advising on the bond market and has helped PSMC in the past).

The end result of the evaluation is that PSMC should consider “refinancing” the 2006 bonds when they mature in March of 2021 because it is likely that a refinance would result in overall savings to PSMC due to reduced interest rates. We obviously cannot know what the market will be like in 18 months, but Hilltop Securities stated it is more likely than not that bond rates (currently at or near an all-time low) would be lower than our current rates (current rates are 5% through 2021 and 4.85% through 2036). There are options to “refinance” the bonds prior to their maturity but these options are not as desirable as waiting until maturity because penalties/premiums for early refunding would reduce/eliminate the savings otherwise resulting from the refinance.

Sherman & Howard affirmed that it is appropriate and legal for PSMC to refinance the 2006 bonds (without further voter approval) so long as we terms of the May 2, 2006 ballot question which should not be an issue (note, the approved ballot question requires no greater than par debt of $12,000,000, repayment costs not to exceed $33,500,000, effective interest rate not to exceed 8.5% and redemption prior to maturity not to exceed premium of 3%).

ORAL REPORTS 4a.v.

60

1 0 010

22

2

27

0 00

102030405060708090

100

Num

ber o

f 911

Res

pons

es

EMS 911 Response

2019

122Total 911 Responses:

0

6

2

Breakdown of EMS Standbys

Fire/SAR/LE/USF

Paid

Special Event (Not Paid)

Refusal

Total Standbys8

44

23

0

10

20

30

40

50

Num

ber o

f Int

erfa

cilit

y Tr

ansp

orts

Total Interfacility Transports

2019 2018

Operations Report -

EMS

August 2019

July

USJHSD Operations Report USJHSD Board Packet, 08-27-2019

Page 1 of 9

WRITTEN REPORTS 4b.i.

0

23

1 1 1 0

17

1 0 0 00

5

10

15

20

25

30

35

40

Num

ber o

f Tra

snpo

rts

Interfacility Transports by Destination

0

0.5

1

1.5

2

2.5

3

Flight/ShuttleCrew

3rd/4th Crew Dispatch Error Assist at PSMC Walk-In EMS Public Assist

0

2

0

3

0 0

"Oth

er"

Calls

Other EMS Calls

2019

EMS


Page 2 of 9


Oncology/Infusion

Oncology Visits Infusion Encounters Oncology Infusions/Injections2019 80 79 80

80 79 80

0102030405060708090

100

Oncology/Infusion

Oncology Visits Infusion Encounters Oncology Infusions/Injections


Page 3 of 9


ED

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec2019 481 451 543 462 563 561 7022018 619 532 554 470 532 589 713 592 543 473 425 629

0

100

200

300

400

500

600

700

800

Num

ber o

f pat

ient

s

ED Yearly Volume Comparison

2019 2018

38 4130 36

0

100

200

300

400

500

600

Admits Transfers

Num

ber o

f Pat

ient

s

ED Inpatient Admissions and Transfers Monthly Comparison

2019 2018


Page 4 of 9


Average Daily Census

22.7Average Length of Stay (in hours)

2.3

32

1 1

0

2

4

6

8

10

12

14

Diagnostic Imaging Gen Surg Ortho Bed Avail

Num

ber o

f Tra

nsfe

rs

JulyED Resource Related Transfers -

ED


Page 5 of 9


Inpatient

Average Daily Census Average Length of Stay (in days)

4.7 2.5

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec2019 37 28 40 31 27 39 382018 50 41 44 34 33 44 41 38 36 29 21 39

0

10

20

30

40

50

60

Inpa

tient

Adm

issio

ns

Inpatient Admission Comparison

2019

2018


Page 6 of 9


Diagnostic Imaging

1482

1057

1337

993

0

200

400

600

800

1000

1200

1400

1600

Procedures Patients

Diagnostic Imaging Stats by Month

2019 2018

2019

2018

0

10

20

30

40

2D Echo Stress Echo2019 38 92018 33 2

38

9

33

2

Cardiology

2019 2018


Page 7 of 9


Lab

5299

1818

4954

1816

0

1000

2000

3000

4000

5000

6000

Tests Patients

Lab Test & Patient Volume by Month

2019 2018

Clinic

1518

448

1504

437

0

200

400

600

800

1000

1200

1400

1600

PCP Encounters Speciality Clinic Encounters

Rural Health Clinic Encounters by Month

2019 2018


Page 8 of 9


20.8

17.4

0

5

10

15

20

25

30

35Average Daily Walk-Ins

2019 2018

Surgery

0

5

10

15

20

25

30

35

40

GI Cases General Ortho ENT GYN Eye PainMgmt

Other

24

13

35

7

0 0

13

0

30

10

39

0 0 0

7

0

Num

ber o

f Cas

es

Surgery Cases by MonthJuly

Clinic


Page 9 of 9


USJHSD Medical Staff Report

USJHSD Board Packet, 08-27-2019

Page 1 of 1

THE UPPER SAN JUAN HEALTH SERVICE DISTRICT

DOING BUSINESS AS PAGOSA SPRINGS MEDICAL CENTER

MEDICAL STAFF REPORT BY VICE CHIEF OF STAFF, DR. CORINNE REED

August 27, 2019

I. STATEMENT OF THE MEDICAL STAFF’S RECOMMENDATIONS FOR THE USJHSD BOARD ACCEPTANCE

OF NEW POLICIES OR PROCEDURES ADOPTED BY THE MEDICAL STAFF:

II. STATEMENT OF THE MEDICAL STAFF’S RECOMMENDATIONS FOR THE USJHSD BOARD ACCEPTANCE

OF PROVIDER PRIVILEGES (ACCEPTANCE BY THE BOARD RESULTS IN THE GRANT OF PRIVILEGES):

NAME INITIAL/REAPPOINT/CHANGE TYPE OF PRIVILEGES SPECIALTY

William Eckhart, MD Initial Appointment Telemedicine/Teleneurology Neurology

Kathryn Lundvall, LPC Initial Appointment AHP/Licensed Professional

Counselor

Licensed Professional

Counselor

Ashley Smith, MD Initial Appointment Telemedicine/Telepsychiatry Psychiatry

David Weiss, MD Initial Appointment Telemedicine/Telepsychiatry Psychiatry

III. REPORT OF NUMBER OF PROVIDERS BY CATEGORY

Active: 17

Courtesy: 29

Telemedicine: 121

Allied Health Professionals: 29

Total: 196

WRITTEN REPORTS 4b.ii.

USJHSD Regular Board Meeting Minutes

07/23/2019

Page 1 of 3

MINUTES OF REGULAR BOARD MEETING

Tuesday, July 23, 2019

5:30 PM

The Board Room

95 South Pagosa Blvd., Pagosa Springs, CO 81147

The Board of Directors of the Upper San Juan Health Service District (the “Board”) held its regular board

meeting on July 23, 2019, at Pagosa Springs Medical Center, The Board Room, 95 South Pagosa Blvd.,

Pagosa Springs, Colorado.

Directors Present: Chair Greg Schulte, Vice-Chair Matt Mees, Treasurer-Secretary Dr. King Campbell,

Director Kate Alfred, Director Dr. Jim Pruitt, Director Karin Daniels, and Director Jason Cox.

1) CALL TO ORDER

a) Call for quorum: Chair Schulte called the meeting to order at 5:30 p.m. MDT and Clerk of the

Board, Heather Thomas, recorded the minutes. A quorum of directors was present and

acknowledged by Treasurer/Secretary Dr. Campbell.

b) Board member self-disclosure of actual, potential or perceived conflicts of interest: There were

none.

c) Approval of the Agenda: The Board noted approval of the agenda.

2) PUBLIC COMMENT

Katie Harr, newly appointed Archuleta County Combined Dispatch Manager, introduced herself

to the Board and noted that she looks forward to working with the District.

3) REPORTS

a) Oral Reports

i) Chair Report

Chair Schulte discussed the recent meeting of the IGA subcommittee of the Archuleta

County Combined Dispatch Executive Management Board held on July 1, 2019, noting that

he asked the attending SUN reporter to leave the meeting, not realizing there was an inadvertent

quorum present.

Chair Schulte further explained the subcommittee serves as an advisory body to the

Dispatch Executive Management Board. Chair Schulte reported that Vice-Chair Mees has

CONSENT AGENDA 5b.i.


07/23/2019

Page 2 of 3

volunteered to serve on the subcommittee with Chair Schulte, unless another Board member

desires to be considered.

Chair Schulte advised what was discussed at the July 1 meeting noting that the next meeting

is to be held July 29 at Town Hall, and will be open to the public.

Questions were asked and answered.

ii) Contracts

Item intentionally struck from agenda. There was no report.

iii) Strategic Planning

Item intentionally struck from agenda. There was no report.

iv) CEO Report

CEO, Dr. Webb advised the Board that she had recently attended the Colorado Hospital

Association (“CHA”) CEO Forum consisting only of CEOs of the CHA-member hospitals,

noting highlights of what had been discussed at the forum. A discussion ensued.

Questions were asked and answered.

v) Finance Report

CFO, Chelle Keplinger, presented and discussed the financial PowerPoint presentation

noting additional verbiage to the presentation.

Director Alfred asked a question regarding if the reported reduction in revenue in June

might possibly be due to reduction in population during that month. CFO Keplinger answered.

Director Dr. Pruitt asked questions regarding what month the Charge Master had been

updated, about surgery revenues, about a typo in the monthly trends report on lines 26 and 27.

CFO Keplinger, CNO-COO Kathee Douglas and Controller Johna Lederhouse answered.

Questions regarding gross and net revenue were asked and answered.

b) Written Reports

i) Operations Report

There were no questions.

ii) Medical Staff Report

There were no questions.

4) CONSENT AGENDA

Director Dr. Pruitt motioned to approve the noted Board member absences, the minutes of the

regular meeting of 06/25/2019, and the Medical Staff report recommendations for new or renewal of

provider privileges. Directors Cox and Daniels noted abstention from approval of the minutes of the

regular meeting of 06/25/2019 due to their absence from the meeting.

Upon motion seconded by Treasurer-Secretary Dr. Campbell, the Board unanimously approved

said consent agenda items with noted abstention by Directors Cox and Daniels.

5) EXECUTIVE SESSION



07/23/2019

Page 3 of 3

The Board did not meet in executive session.

6) OTHER BUSINESS

There was no other business.

7) ADJOURN

There being no further business, Chair Schulte adjourned the regular meeting at 6:18 p.m. MDT.

Respectfully submitted by:

Heather Thomas, serving as Clerk of the Board


UPPER SAN JUAN HEALTH SERVICES DISTRICT

D/B/A PAGOSA SPRINGS MEDICAL CENTER

Formal Written Resolution 2019-07

August 27, 2019

WHEREAS, the Board of Directors of Upper San Juan Health Service District

(“USJHSD”) desires to adjust its regular meeting schedule for September and October of

2019.

NOW, THEREFORE, THE BOARD OF DIRECTORS OF THE UPPER SAN JUAN

HEALTH SERVICE DISTRICT HEREBY RESOLVES to change its regular Board of

Directors meeting schedule as follows:

Cancel the regular meeting on Tuesday, September 24, 2019, and instead the Board

will attend the PSMC Community Open House on Thursday, September 26, 2019

from 5:15 p.m. until 7:15 p.m.

Cancel the regular meeting on Tuesday, October 22, 2019, and instead hold a

special meeting of the Board of Directors on Tuesday October 15, 2019 (to allow

presentation of the 2020 budget prior to the October 15th statutory deadline).

The resulting schedule for the Board of Directors will be:

o Thursday, September 26th from 5:15 to 7:15 p.m.;

o Tuesday, October 15th at 5:30 p.m. (standard agenda, presentation of August

financials and presentation of the 2020 budget);

o Tuesday, November 19th at 5:30 p.m. (standard agenda, presentation of

September and October financials, approval of the 2020 budget); and

o Tuesday December 17th at 5:30 p.m. (standard agenda and presentation of

November financials).

_____________________________________________

Greg Schulte, as Chairman of the Board of Directors of USJHSD

DECISION AGENDA 6.a.

Documents

(direct access northeast entrance) AGENDA 1) CALL TO ORDER ...pagosaspringsmedicalcenter.org/wp-content/uploads/... · 8/27/2019 · 2017 initiatives. This saves our patients the