UNM Hospitals Board of Trustees III. ADOPTION OF AGENDA ......Nov 30, 2018 · Belmonte, Jessica,...

UNM Hospitals Board of Trustees

OPEN SESSION – AGENDA Friday, November 30, 2018 at 9:00 AM

Barbara and Bill Richardson Pavilion Conference Room 1500

I. CALL TO ORDER – Jerry McDowell, Ph.D., Chair, UNM Hospital Board of Trustees II. ANNOUNCEMENTS (Informational)

Chief of Staff Update – Jennifer Phillips, MD

III. ADOPTION OF AGENDA (Approval/Action)

IV. CONSENT APPROVAL/INFORMATIONAL ITEMS

Disposition of Assets (Informational) Repair, Renew, Replace Capital Project – ACC Roof Replacement -- $1,830,000.00 (Approval) Repair, Renew, Replace Capital Project – Pneumatic Tube System -- $950,000.00 (Approval)

V. PUBLIC INPUT (Informational)

VI. APPROVAL OF THE MINUTES

October 26, 2018 UNMH Board of Trustees Meeting Minutes – Jerry McDowell, Ph.D., Chair (Approval/Action)

VII. MISSION MOMENT – Kate Becker (Informational)

VIII. OCTOBER ACTION ITEMS (Informational)

IX. BOARD INITIATIVES

Chairman’s Report – Jerry McDowell, Ph.D., Chair (Informational)

Org Structure – Kate Becker (Informational)

Board of Trustees Conference/Training – Kate Becker (Informational)

X. ADMINISTRATIVE REPORTS (Informational)

Chancellor for Health Sciences - Paul Roth, MD

HSC Committee Update – Michael Richards, MD

CEO Report UNM Hospitals – Kate Becker

100 Day On the Job Report – Kate Becker

UNM Board of Regents Update – Kate Becker

CMO Report UNM Hospitals – Irene Agostini, MD XI. COMMITTEE REPORTS (Informational)

Quality and Safety Committee – Raymond Loretto, DVM

Finance, Audit & Compliance Committee – Terry Horn

Native American Services Committee – Erik Lujan

Community Engagement Committee – Christine Glidden XII. OTHER BUSINESS

October Financials – Bonnie White (Informational)

XIII. CLOSED SESSION: Vote to close the meeting and to proceed in Closed Session (Approval/Action – Roll Call Vote) a. Discussion of limited personnel matters pursuant to Section 10-15-1.H (2), NMSA pertaining to the

appointment and reappointment of medical providers to the medical staff of UNM Hospital and expansion of medical staff privileges for certain UNM Hospital medical staff providers, including the discussion of matters deemed confidential under the New Mexico Review Organization Immunity Act, Sections 41-9-1E(7) and 41-9-5, NMSA” as to the following:

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Permanent Appointments

Awad, Sawsan, MD Pediatrics

Cano Vazquez, Nadia, CNP Internal Medicine

Draper, Danielle, MD Family & Community Medicine

Edmiston, Margaret, CNP Psychiatry

Fattor-Rivera, Kristin, CNP Internal Medicine

George, Naomi, MD Emergency Medicine

Huang, Jana, AA-C Anesthesiology

Jinkins, Lindsay, MD Anesthesiology

Lauria, Genevieve, CNP Emergency Medicine

Morrell, Nathan, MD Orthopedics

Natharius, Kristin, CNP Surgery

Pritchard, Aaron, MD Pathology

Schmidt, Jordan, AA-C Anesthesiology

Tokuda, Nathan, MD Pathology

Torres, Rosalicia, MD Family & Community Medicine

Varga, Peter, MD Pediatrics

Reappointments

Adjei Poku, Yaw, MD Internal Medicine

Angeli,Eva, MD Internal Medicine

Atweh, George, MD Internal Medicine

Barrett, Douglas, MD Neurology

Belmonte, Jessica, MD Internal Medicine

Bettler, John, MD Family & Community Medicine

Bieniarz, Mark, MD Internal Medicine

Bissell, Elena, MD Family & Community Medicine

Boyne, Patric, PA-C Family & Community Medicine

Castillo, Ricardo, MD Pediatrics

Chow, Christal, MD Pediatrics

Cornelius, Hannah, PA-C Emergency Medicine

Daher, Amine, MD Pediatrics

Dammad, Tarek, MD Internal Medicine

Das, Arup, MD Surgery

Davis, Rachel, MD Surgery

De la Garza, Janet, CNS Internal Medicine

Finley, William, CNP Internal Medicine

Fisk, James, MD Pediatrics

Gray, John, PsyD Family & Community Medicine

Henderson, David, CNP Pediatrics

Kessinger, Mimi, PA-C Internal Medicine

Kraai, Erik, MD Internal Medicine

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Madrid, Samantha, CNP Family & Community Medicine

McGuire, Elizabeth, MD Internal Medicine

Melton, Elizabeth, CNP Emergency Medicine

Morgan, Caitlin, CNP Surgery

Parks, Lauren, PhD Psychiatry

Rabinowitz, Ian, MD Internal Medicine

Raizada, Veena, MD Internal Medicine

Rohrscheib, Mark, MD Internal Medicine

Sheldon, Mark, MD Internal Medicine

Shevy, Laura, MD Internal Medicine

Sladen, Jamie, PA-C Neurosurgery

Taylor, Betsy, MD Obstetrics & Gynecology

Thoma, Robert, PhD Psychiatry

Tran, Huy Q., MD Neurosurgery

Vu, Linda, PA-C Surgery

Wernly, Jorge, MD Surgery

Wichman, Jennifer, CNP Surgery

Worsham, Anthony, MD Internal Medicine

Yonke, Nicole, MD Family & Community Medicine

Expansion of Privileges and/or Change in Department

Blanton, Cheyenne, PA-C Internal Medicine

Botros, James, MD Neurosurgery

Carlson, Andrew, MD Neurosurgery

Chohan, Muhammad, MD Neurosurgery

De la Garza, Janet, CNS Internal Medicine

Hamming, Zwaantje, CNP Internal Medicine

Kessinger, Mimi, PA-C Internal Medicine

Lacerda, Gwen, MD Neurosurgery

Lewis, Jeremy, MD Neurosurgery

McKee, Rohini, MD Surgery

Melendres-Groves, Lana, MD Internal Medicine

Ninivaggio, Cara, MD OB/GYN

Rabinowitz, Ian, MD Internal Medicine

Rivers, William, DO Neurosurgery

Sheffield, Amy, CNP Internal Medicine

Sheldon, Mark, MD Internal Medicine

Shin, Peter, MD

- UNMH Fluoroscopy on-core

Neurosurgery

Taylor, Christopher, MD

- UNMH Fluoroscopy non-core

Neurosurgery

Yau, Raymond, MD


Internal Medicine

Yonas, Howard, MD


Neurosurgery

Yonke, Nicole, MD

- UNMH Family Medicine: Attendance at delivery

to assume care of

normal newborns non-core

Family & Community Medicine

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b. Discussion of matters involving strategic and long-range business plans or trade secrets of UNMH pursuant to Section 10-15-1.H (9), NMSA.

c. Vote to re-open the meeting (Approval/Action) XIV. Certification that only those matters described in Agenda Item XII were discussed in Closed

Session; consideration of, and final action on the specific limited personnel matters discussed in Closed Session. (Approval/Action)

XV. Adjourn Meeting (Approval/Action)

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Chief of Staff Update

Separator Page

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UNMH MEDICAL STAFF

CHIEF OF STAFF REPORT TO BOARD OF TRUSTEES MEETING OF NOVEMBER 30TH, 2018

Clinical/ Quality/Patient Safety/Regulatory

Dr. Mike Chicarelli is named COO of UNMH! Congrats!!

New Chief of Staff starts 1/2019- Dr. Davin Quinn of the department of Psychiatry has been

elected. I will still be attending the board meetings as a board of trustee for two years.

Medical Executive Members at Large election- Valerie Carrejo, MD from the department of

Family and Community Medicine and Dusadee Sarangarm, MD from the department of

Emergency Medicine will be our next members at large on the Medical Executive Committee

each serving a two year term.

TJC has come and per Dr. Pitcher’s message to medical staff: “The TJC surveyors were all

uniformly impressed by the overall quality of, and the commitment of our medical staff

and house staff to assuring the highest quality and safest care for our patients.” From

the meeting with the board and leadership- they could really feel the “strength of our

mission.” As always, there were some opportunities for improvement and we are

working quickly to address them.

Research

There is large initiative led by Dr. Brandi Fink to reduce opioid use disorder in our state by 40%

over 4 years. The grant is worth 110M. We will be submitting in one week and we will hear

about whether or not it is funded in March. It will involve 20 different municipalities and will

address treatment, prevention and interactions with the justice system.

Education

An ad-hoc committee of the UNMH Medical Staff met and created an evidence-based peer reviewed FAQ form for the medical staff to answer questions about New Mexico’s Medical Cannabis program. The document was also adopted at SRMC by their Medical Executive Committee.

Diversity

Alisha Parada, MD was named Vice Chair for Diversity and Inclusion in the Department of

Internal Medicine earlier this year. Marlene Ballejos, PhD was named Vice Chair for Diversity,

Equity and Inclusion in the Department of Family and Community Medicine this October. They

are two of a hand-full of leaders in the continued efforts to value and celebrate Diversity at

UNM HSC.

Community

Mill levy passed in Sandoval County! This will support SRMC and the larger mission of UNMHSC.

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Disposition of Assets

Separator Page

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Date: November 14, 2018

To: Bruce Cherrin

Chief Procurement Officer, Purchasing Department

From: Bonnie White

Interim Chief Financial Officer, UNM Hospitals

Subject: Property Disposition – November 2018

Attached for your review and submission to the Board of Regents is the Property Disposition

Detail list for the month of November 2018.

Consistent with UNM Board of Regents Policy 7.9 Property Management and the Disposition of

Surplus Property Act, 13-6-1, NMSA 1978, and based upon documentation submitted by the

UNM Hospitals’ departments responsible for the equipment, I certify that the equipment

identified on the list is worn-out, unusable/unlocated or beyond useful life to the extent that the

items are no longer economical or safe for continued use by UNM Hospitals. I recommend that

the items be deleted from UNM Hospitals inventory and disposed of in accordance with the

above noted Regents Policy and Surplus Property Act.

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Count Acquisition Cost Book Value Average Age

Monitor Upgrade Project 355 3,858,167.72$ 54,792.36$ 10.83

Unable to Inventory 54 863,615.57$ 24,710.10$ 10.74

Grand Total 409 4,721,783.29$ 79,502.46$ 10.81Property Disposition requestNovember 2018

Lawson

Number

Asset

Control

Number

DescriptionAccounting

UnitDivision Description Model Serial Number

Acquisition

Date

Acquisiton

Cost

Book

Value

Proposed Method of

DisposalReason for Disposal Comments

1567 43095 SLR 8M BSIC/Hi-Res CRG Eng 100 12455 Newborn ICU SOLAR 8000M K1RF7952G 12/01/01 8,865.37$ -$ Auction Replaced Monitor Project










1815 SCOPE CF-Q160L Video Colonoscope 70020 Endoscopy Center CF-Q160L 2202681 04/01/02 22,625.00$ -$ None Unable to Inventory

1817 SCOPE CF-Q160L Video Colonoscope 70020 Endoscopy Center CF-Q160L 2202845 04/01/02 22,625.00$ -$ None Unable to Inventory

2763 BULK Computer Workstations With Ass 34110 Women's Health Center C1 32 4.25-S C1 32 4.25-S 07/01/03 13,568.10$ -$ None Unable to Inventory

2848 46590 SLR8M Sngl Card Monitor, Multi 15000 Operating Room SOLAR 8000 F3G46198G 09/01/03 10,002.72$ -$ Auction Replaced Monitor Project

2851 46589 SLR8M Sngl Card Monitor, Multi 15000 Operating Room SOLAR 8000 F3G46202G 09/01/03 10,002.72$ -$ Auction Replaced Monitor Project

3861 46280 DASH 4000 Monitor Capitalize C 95700 Clinical Engineering C3DJ6904G C3DJ6904G 05/01/03 11,953.23$ -$ Auction Replaced Monitor Project

3874 46006 DASH 4000 Monitor Capitalize C 21015 ED-North DASH 4000 G2DJ6567G 05/01/03 12,257.60$ -$ Auction Replaced Monitor Project

3876 46010 DASH 4000 Monitor Capitalize C 21015 ED-North DASH 4000 G2DJ6574G 05/01/03 12,257.60$ -$ Auction Replaced Monitor Project

3878 46011 DASH 4000 Monitor Capitalize C 21020 Pediatric Emergency Department DASH 4000 G2DJ6576G 05/01/03 12,257.60$ -$ Auction Replaced Monitor Project

3893 46009 DASH 4000 Monitor Capitalize C 21015 ED-North DASH 4000 H2DJ7320G 05/01/03 12,257.60$ -$ Auction Replaced Monitor Project

3896 46007 DASH 4000 Monitor Capitalize C 21015 ED-North DASH 4000 H2DJ7336G 05/01/03 12,257.60$ -$ Auction Replaced Monitor Project

3988 46524 UPA-P100MD/OFM Digital Video C 70020 Endoscopy Center UPA-P100MD 10421 08/01/03 6,880.00$ -$ None Unable to Inventory

4263 49319 Maternal/Fetal Monitor 12000 Labor and Delivery 129 RUX04263833PA 08/01/04 15,672.02$ -$ None Unable to Inventory

4264 49318 Maternal/Fetal Monitor 12000 Labor and Delivery 129 RUX04273847PA 08/01/04 15,672.02$ -$ None Unable to Inventory

5137 None Cardiac X-Ray NEMA/SCAI XR-21 71040 Cardiac Cath Lab SCAI XR-21 SCAI XR-21 12/01/05 5,745.00$ -$ None Unable to Inventory

5635 54352 Combi Ovens, Stacked 84000 Food and Nutrition LCG141M 4868172001 11/01/05 29,799.00$ -$ None Unable to Inventory

5645 52228 Solar 8000I 12130 Trauma/Surgical ICU SOLAR 8000I SBM05240063GA 11/01/05 9,919.35$ -$ Auction Replaced Monitor Project


















5667 52403 CIC - Central Station 12130 Trauma/Surgical ICU CIC JA105232101GA 11/01/05 23,712.13$ -$ Auction Replaced Monitor Project

5676 52450 BIS/EEG Module 12110 Neuroscience ICU BIS/EEG MODULE RBM05200514GA 11/01/05 5,920.00$ -$ Auction Replaced Monitor Project



5745 None NAI DICOM Imaging Box - UMC 400C DICOM12000 Labor and Delivery UMC 400C UMC 400C 07/01/06 9,567.03$ -$ None Unable to Inventory

5862 58553 Tram, 12SL, Dinamap NIBP 95700 Clinical Engineering 451 RTW06070784GA 04/01/07 7,886.25$ -$ Auction Replaced Monitor Project

5902 58592 MAC 5500 Electrocardiograph Mo 12455 Newborn ICU MAC 5500 SCH07110765GA 04/01/07 71,999.50$ -$ Auction Replaced Monitor Project

6098 SW Life Solutions Upgrade 75045 Radiology - Nuclear Med Software Software 07/01/06 17,000.00$ -$ None Unable to Inventory

6104 58184 Transport Pro V2 12455 Newborn ICU PRO V2 AAD06231788GA 06/10/07 6,650.00$ -$ Auction Replaced Monitor Project

6105 58185 Transport Pro V2 12455 Newborn ICU PRO V2 AAD06241802GA 06/10/07 6,650.00$ -$ Auction Replaced Monitor Project

6119 60018 CIC & Touch Screen Monitor 12110 Neuroscience ICU CIC JA106486245GA 06/09/07 18,301.50$ -$ Auction Replaced Monitor Project

6120 58438 Solar 8000I 12110 Neuroscience ICU 8000I SBL06163870GA 06/09/07 11,027.24$ -$ Auction Replaced Monitor Project





6127 58380 Solar 8000I 12110 Neuroscience ICU 8000I SBL06163869GA 06/09/07 11,027.24$ -$ Auction Replaced Monitor Project9/44




6131 58602 CO2 Module 12110 Neuroscience ICU RCK06241008GA RCK06241008GA 06/09/07 6,184.50$ -$ Auction Replaced Monitor Project





6137 58597 BIS Module 12110 Neuroscience ICU BIS RBM06241118GA 06/09/07 5,705.00$ -$ Auction Replaced Monitor Project





6144 60716 CIC 4.1 12455 Newborn ICU CIC 4.1 JA106074165GA 06/10/07 24,162.00$ -$ Auction Replaced Monitor Project

6159 58777 Solar 8000I 12455 Newborn ICU 8000I SBL06163827GA 06/10/07 11,789.14$ -$ Auction Replaced Monitor Project










6170 58779 Solar 8000I 12455 Newborn ICU RCK06241008GA SBL06163837GA 06/10/07 11,789.14$ -$ Auction Replaced Monitor Project

















6188 60089 Tram 451 N 95700 Clinical Engineering 451 N 5BB06210683GA 06/10/07 6,829.20$ -$ Auction Replaced Monitor Project



6201 62132 MAC 5500 EKG Machine 34540 Sports Medicine MAC 5500 SCD0706719PA 07/01/07 12,201.00$ -$ None Unable to Inventory

7000 58341 Solar 8000I Capitalize CIP 163 12120 Medical/Cardiac ICU SOLAR 8000I SBL06436132GA 07/01/07 10,199.96$ -$ Auction Replaced Monitor Project









7011 58361 Tram 451N Capitalize CIP 1630 95700 Clinical Engineering TRAM 451N SBB06442693GA 07/01/07 8,335.12$ -$ Auction Replaced Monitor Project







7021 58637 Solar 8000I Capitalize CIP 163 12130 Trauma/Surgical ICU SOLAR 8000I SBL06436160GA 07/01/07 12,424.09$ -$ Auction Replaced Monitor Project












7035 58723 Tram 451N Capitalize CIP 1630 95700 Clinical Engineering TRAM 451N SBB06432637GA 07/01/07 8,335.13$ -$ Auction Replaced Monitor Project10/44

7037 58499 Central Information Center Cap 12460 Pediatric ICU CIC JA106486182GA 07/01/07 21,750.30$ -$ Auction Replaced Monitor Project

7038 58655 Solar 8000I Capitalize CIP 163 12460 Pediatric ICU SOLAR 8000I SBL06436184GA 07/01/07 10,335.05$ -$ Auction Replaced Monitor Project








7046 58678 Tram 451N (Part of Asset in Di 95700 Clinical Engineering TRAM 451N SBB06442708GA 07/01/07 5,465.63$ -$ Auction Replaced Monitor Project

7088 64643 Dash 3000 12230 Gen Med/SAC (4-W) DASH 3000 SD008015038GA 04/01/08 9,061.44$ -$ None Unable to Inventory

7090 None CIC - 12BEDV 12230 Gen Med/SAC (4-W) CICV5 CICV5 04/01/08 32,753.23$ -$ None Unable to Inventory

7092 None CIC 12BEDM 12230 Gen Med/SAC (4-W) CICV5 CICV5 04/01/08 14,063.23$ -$ None Unable to Inventory

7093 None CIC 10BEDV 12230 Gen Med/SAC (4-W) CICV5 CICV5 04/01/08 29,708.23$ -$ None Unable to Inventory

7153 SW Software for Capillary Glucose 90030 Lab - Admin Software Software 04/01/08 19,200.00$ -$ None Unable to Inventory

7154 None Hardware for Capillary Glucose 90030 Lab - Admin Hardware Hardware 04/01/08 10,100.00$ -$ None Unable to Inventory

7279 58715 Dash 4000 Capitalize CIP 1630 15045 PACU - BBRP DASH 4000 SBG06462664GA 07/01/07 10,134.86$ -$ Auction Replaced Monitor Project

7293 60742 Tram 451N Capitalize CIP 1630 95700 Clinical Engineering 451N SBB06442699GA 07/01/07 8,236.14$ -$ Auction Replaced Monitor Project



7297 None Tram 451N Capitalize CIP 1630 95700 Clinical Engineering 451N 451N 07/01/07 8,236.14$ -$ None Unable to Inventory

7298 None Tram 451N Capitalize CIP 1630 95700 Clinical Engineering 451N 451N 07/01/07 8,236.14$ -$ None Unable to Inventory

7301 60032 CIC Capitalize CIP 1630 Med Eq 21010 ED - Fast Track CIC JA106486192GA 07/01/07 36,369.30$ -$ Auction Replaced Monitor Project

7303 58939 Dash 4000 Capitalize CIP 1630 21010 ED - Fast Track DASH 4000 SBG06452038GA 07/01/07 11,764.74$ -$ Auction Replaced Monitor Project












7318 60028 CIC Capitalize CIP 1630 Med Eq 21015 ED-North CIC JA106486205GA 07/01/07 48,332.26$ -$ Auction Replaced Monitor Project

7319 60030 CIC Capitalize CIP 1630 Med Eq 21015 ED-North CIC JA106486179GA 07/01/07 48,332.26$ -$ Auction Replaced Monitor Project






7329 58990 Solar 8000I Capitalize CIP 163 21015 ED-North SOLAR 8000I SBL06436155GA 07/01/07 10,788.78$ -$ Auction Replaced Monitor Project







7339 60005 Dash 4000 (with Div 02 Asset 3 21020 Pediatric Emergency Department DASH 4000 SBG06452031GA 07/01/07 10,589.32$ -$ Auction Replaced Monitor Project


7350 58330 CIC Capitalize CIP 1630 Med Eq 12455 Newborn ICU CIC JA106486248GA 07/01/07 21,469.80$ -$ Auction Replaced Monitor Project

7351 58333 CIC Capitalize CIP 1630 Med Eq 12110 Neuroscience ICU CIC JA106486235GA 07/01/07 21,469.80$ -$ Auction Replaced Monitor Project

7352 58435 Solar 8000I Capitalize CIP 163 12110 Neuroscience ICU SOLAR 8000I SBL06436173GA 07/01/07 10,170.82$ -$ Auction Replaced Monitor Project




















7378 58431 Tram 451N Capitalize CIP 1630 95700 Clinical Engineering 451N SBB06432572GA 07/01/07 8,335.14$ -$ Auction Replaced Monitor Project11/44




7383 58904 Dash 4000 Capitalize CIP 1630 21015 ED-North DASH 4000 SBG06452043GA 07/01/07 11,340.56$ -$ Auction Replaced Monitor Project

7525 67210 Misuho OSI Imaging Table 15000 Operating Room OSI 5671 06/01/08 56,380.00$ -$ None Unable to Inventory

7878 62371 Tram 451N 95700 Clinical Engineering TRAM 451N SBB07174566GA 09/01/07 7,362.00$ -$ Auction Replaced Monitor Project











7895 62385 Solar 8000I 12455 Newborn ICU SOLAR 8000I SBL07189836GA 09/01/07 5,192.30$ -$ Auction Replaced Monitor Project














7930 62635 Neurofax (EEG) 78010 Neurodiagnostics Lab JE-921A 01267 12/01/07 12,634.07$ -$ None Unable to Inventory

7931 62815 CIC Pro 12415 Intermediate Care Nursery CIC PRO SCH07422647GA 01/01/08 44,935.21$ -$ Auction Replaced Monitor Project

7932 62829 Solar 8000I 12415 Intermediate Care Nursery SOLAR 8000I SCZ07423135GA 01/01/08 13,670.94$ -$ Auction Replaced Monitor Project





















8100 MOD EW7 Image Capture Work Station 70010 Digestive Disease Procedures EW7 0080004 07/01/08 7,136.66$ -$ None Unable to Inventory

8101 MOD EW7 Image Capture Work Station 70010 Digestive Disease Procedures EW7 0080005 07/01/08 7,136.66$ -$ None Unable to Inventory

8506 None Sonic Irrigator Digital 110V 15010 Sterile Processing SONIC 0109 45681 08 06/01/09 13,329.00$ -$ None Unable to Inventory

8518 STERILE P04102-06 Transducer 32045 Southwest Mesa Clinic P04102-06 RIC5-9-D 06/01/09 8,050.00$ -$ None Unable to Inventory

8519 STERILE P04102-06 Transducer 32045 Southwest Mesa Clinic P04102-.06 03G7TC 06/01/09 8,050.00$ -$ None Unable to Inventory

8577 68440 Tram 451N and Tram Rack for MA 71040 Cardiac Cath Lab 451N SBB080507943GA 05/01/09 10,327.50$ -$ Auction Replaced Monitor Project

8740 73724 NK - Digital Video EEG System 78010 Neurodiagnostics Lab EEG9200 7GST4J1 09/01/09 35,026.57$ -$ None Unable to Inventory

8793 58560 Solar 8000i 12120 Medical/Cardiac ICU SOLAR 8000I SE409341447GA 10/01/09 12,193.30$ -$ Auction Replaced Monitor Project











8806 73832 Transport Pro-V2 Monitor 15055 Anesthesia PRO-V2 SCS09384092GA 11/01/09 6,125.00$ -$ Auction Replaced Monitor Project

8807 73833 Transport Pro-V2 Monitor 15055 Anesthesia PRO-V2 SCS09384089GA 11/01/09 6,125.00$ -$ Auction Replaced Monitor Project

8860 70055 CICV5+MP100D Monitor 21015 ED-North MP100D 1084177 03/01/10 35,219.55$ -$ Auction Replaced Monitor Project12/44

8862 70039 Dash 4000 Monitor 21010 ED - Fast Track 4000 SD009441239GA 11/01/09 15,222.18$ -$ Auction Replaced Monitor Project






8900 73469 AIDA DVD-M with Smart Screen A 15500 OSIS Operating Room 2024520 EA661533-P 08/01/09 16,657.04$ -$ None Unable to Inventory

9094 None Portable Fiber Intubation Scop 12130 Trauma/Surgical ICU FI-13BS G110621 06/01/10 7,114.80$ -$ None Unable to Inventory

9182 None MSVP Medison Accuvix Sonoace P 34120 Repro/Endo Clinic 3D5-8EK 100168 06/01/10 6,516.87$ -$ None Unable to Inventory

9183 None MSVP Medison Accuvix Sonoace P 34120 Repro/Endo Clinic 3D5-8EK 93567 06/01/10 6,519.69$ -$ None Unable to Inventory

9243 70883 Solar Capnostat 21010 ED - Fast Track CAPNOSTAT RCJ09352031GA 09/01/10 5,810.00$ -$ Auction Replaced Monitor Project








9420 None RIC5-9-D Probe 34115 Women's Ultrasound Clinic RIC5-9-D RIC5-9-D 02/01/11 6,392.00$ -$ None Unable to Inventory

9512 None Packaged Recorder DTpHZ 70010 Digestive Disease Procedures DIGITRAPPER DTZ10236 05/01/11 8,629.00$ -$ None Unable to Inventory

9514 None Packaged Recorder DTpHZ 70010 Digestive Disease Procedures DIGITRAPPER DTZ10248 05/01/11 8,629.00$ -$ None Unable to Inventory

9576 None PPS Cluster Server - Prescript 77015 Pharmacy - Outpatient PPS Server PPS Server 07/01/10 58,005.00$ -$ None Unable to Inventory

10243 47185 Spectrum Pool Lift 76050 CTH Physical Therapy SWIM LIFT II NONE 04/01/01 5,109.70$ -$ None Unable to Inventory

10430 49809 4V1 Transducer 30030 CTH Outpatient Clinic 4V1 55378 06/01/09 18,500.00$ -$ None Unable to Inventory

14245 None Viking IV Base Computer System 34315 Clinical Neuroscience Center CICV5 CICV5 07/01/95 43,817.79$ -$ None Unable to Inventory

18332 36030 Spectra 500 5-Step Mag w/Video 34245 ENT Clinic FS 1100 21458 09/01/00 7,353.00$ -$ None Unable to Inventory

18575 38021 Zoll Base Power Charger 4X4 71040 Cardiac Cath Lab M SERIES T99J05583 10/01/00 8,640.98$ -$ None Unable to Inventory

18690 38904 External Fetal Monitor 12000 Labor and Delivery 172 13000176 12/01/00 5,569.20$ -$ None Unable to Inventory

19279 None HT50-HI VENTILATOR SYSTEM 70070 Lifeguard Dispatch HT50-H1 HT50-H1 06/01/03 11,940.98$ -$ None Unable to Inventory

19311 None HT50-H1 Ventilator Assy w/o Hu 70070 Lifeguard Dispatch HT50-H1 HT50-H1 08/01/03 11,940.98$ -$ None Unable to Inventory

19328 None HT50-H1 Ventilator Assembly 70070 Lifeguard Dispatch 03092097 03092097 05/01/04 10,007.73$ -$ None Unable to Inventory



19449 52252 Solar 8000I 12460 Pediatric ICU SOLAR 8000I SBM05250080GA 09/01/05 12,795.62$ -$ Auction Replaced Monitor Project

















19511 58872 Dash 4000 21015 ED-North DASH 4000 SBG06462145GA 07/01/07 11,340.56$ -$ Auction Replaced Monitor Project























19536 58897 Dash 4000 21015 ED-North DASH 4000 SBG06452035GA 07/01/07 11,340.56$ -$ Auction Replaced Monitor Project13/44






19543 60474 Transport Pro 21015 ED-North TRANSPORT PRO SCS06440441GA 07/01/07 5,775.00$ -$ Auction Replaced Monitor Project






19553 60036 CIC 21020 Pediatric Emergency Department CIC JA106486180GA 07/01/07 32,112.32$ -$ Auction Replaced Monitor Project

19554 58983 Dash 4000 12480 CTH Rehab-Ortho Unit DASH 4000 SBG06462135GA 07/01/07 11,224.25$ -$ Auction Replaced Monitor Project

19555 58984 Dash 4000 21020 Pediatric Emergency Department DASH 4000 SBG06462311GA 07/01/07 11,224.25$ -$ Auction Replaced Monitor Project











19575 60293 Solar 8000I (w/Div 01 Asset #2 12455 Newborn ICU SOLAR 8000I SBL06426119GA 07/01/07 10,312.26$ -$ Auction Replaced Monitor Project

19815 None Microscope 74120 Lab - 1213 Univ - Blood Bank B-MAX B-MAX 05/01/08 13,348.92$ -$ None Unable to Inventory

19881 68224 Dash 4000 21015 ED-North DASH 4000 SD008484188GA 12/01/08 13,298.92$ -$ Auction Replaced Monitor Project

19882 68223 Dash 4000 21015 ED-North DASH 4000 SD008484190GA 12/01/08 13,298.92$ -$ Auction Replaced Monitor Project

19901 68565 ManoScan 360-Z Modular EG Cart 70020 Endoscopy Center 360-Z CICV5 11/01/08 35,300.00$ -$ None Unable to Inventory

21097 80337 Nellcor Tram 451N5 15055 Anesthesia TRAM 451N5 SBB10319779GA 07/01/11 6,962.90$ -$ Auction Replaced Monitor Project

21432 82776 CIC 12110 Neuroscience ICU CIC PRO SDY11077871GA 06/01/12 6,212.50$ -$ Auction Replaced Monitor Project

21433 82777 CIC 12120 Medical/Cardiac ICU CIC PRO SDY11158745GA 05/01/12 6,212.50$ -$ Auction Replaced Monitor Project

21435 82779 CIC 21025 ED Admission Prep CIC PRO SDY11077872GA 06/01/12 6,212.50$ -$ Auction Replaced Monitor Project

26355 82475 CIC 95700 Clinical Engineering CIC PRO SDY11108111GA 07/01/12 6,212.50$ -$ Auction Replaced Monitor Project

26367 83766 CIC 95710 1213 Clinical Engineering CIC PRO SDY12483762GA 02/01/13 6,212.50$ -$ Auction Replaced Monitor Project

26554 SW NC4 E-Sponder Software 95020 Emergency Management Software Software 11/01/12 55,325.89$ -$ None Unable to Inventory

28862 89101 CIC Pro V5 21015 ED-North CIC PRO SDY13225655GA 09/01/14 27,050.40$ 5,410.08$ Auction Replaced Monitor Project

28934 91412 Transport ATO Model Monitor 12110 Neuroscience ICU TRANSPORT V2 ATO 1040654 09/01/14 6,342.00$ 3,171.00$ Auction Replaced Monitor Project

29332 91152 CIC V5.X Ato Model 21015 ED-North CIC-PRO SDY14372689GA 04/01/15 18,727.20$ 5,930.28$ Auction Replaced Monitor Project

29444 91721 Monitor Central Station 12415 Intermediate Care Nursery CIC V5.X ATO SDY15074280GA 03/01/15 9,036.00$ 2,710.80$ Auction Replaced Monitor Project

29498 91849 Dash 5000 21015 ED-North DASH 5000 SHQ15193AA1SA 06/01/15 11,767.00$ 4,118.44$ Auction Replaced Monitor Project

29499 91850 Dash 5000 21015 ED-North DASH 5000 SHQ151934385SA 06/01/15 11,767.00$ 4,118.44$ Auction Replaced Monitor Project

30535 95281 Dash 5000 Monitor 21015 ED-North DASH 5000 SHQ16124731SA 04/01/16 10,509.37$ 5,429.84$ Auction Replaced Monitor Project



30567 93687 Dash 5000 Monitor 12415 Intermediate Care Nursery DASH 5000 SHQ15263663SA 10/01/15 15,652.56$ 6,521.90$ Auction Replaced Monitor Project

30568 93688 Dash 5000 Monitor 12415 Intermediate Care Nursery DASH 5000 SHQ15263664SA 10/01/15 15,652.56$ 6,521.90$ Auction Replaced Monitor Project

30657 95908 Patient Data Module 12455 Newborn ICU PDM SA315155096GA 06/01/16 9,565.20$ 4,942.02$ None Unable to Inventory





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Repair, Renew, Replace Capital Project – ACC Roof

Replacement

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CAPITAL PROJECT APPROVAL

UNM HOSPITALS – ACC Roof Replacement

November 2018

REQUESTED ACTION:

As required by Section 7.12 of Board of Regents Policy Manual, the New Mexico Higher Education

Department and the New Mexico State Board of Finance, capital project approval is requested for

ACC Roof Replacement.

DESCRIPTION:

Request approval to remove the existing roofing membrane and all of its components, down to concrete

deck, and install new 60 mil TPA (tri-polymer alloy) thermoplastic single ply roof system over tapered

insulation. The construction will replace existing eight dome skylights with new Kalwall skylights.

RATIONALE:

The existing roof has exceeded its life expectancy and has had several temporary patch repairs. The

existing membrane has stretched to the point of imminent failure.

PURCHASING PROCESS: Weatherproofing Technologies, Inc. (WTI) was hired as the project consultant to provide project design

and oversight. These services were procured under WTI’s Vizient contract number CE0360.

Construction firms were invited to view the site. The project was competitively bid; however, the

construction firm has not yet been awarded. The construction contract is anticipated to be completed

by June 30, 2019.

FUNDING:

The total project budget is estimated at and will not exceed $1,830,000. The project will be funded equally

($915,000 each) by the UNM Hospital Capital Fund and by UNMH Health Sciences Center.

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Repair, Renew, Replace Capital Project – Pneumatic

Tube System

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CAPITAL PROJECT APPROVAL

UNM HOSPITALS – UH-Main Pneumatic Tube System Upgrades

November 2018

REQUESTED ACTION:

As required by Section 7.12 of Board of Regents Policy Manual, the New Mexico Higher Education

Department and the New Mexico State Board of Finance, capital project approval is requested for

UH-Main Pneumatic Tube System Upgrades.

DESCRIPTION:

Request approval to upgrade to the Pneumatic Tube System at UH-Main and BBRP. This upgrade will

be conducted in two phases:

Phase I - Provide for the addition of Zone 7 and 8 in BBRP which will include two regenerative

blower packages, and four transfer units connected to Emergency Power. This will include

modification of the existing system in the basement and on the second floor of the BBRP to

accommodate installation of new equipment.

Phase II - Provide Ethernet conversion package to all Swisslog equipment including blowers,

stations, and transfer unit. This phase includes providing Ethernet ports to all equipment, replacing

existing TL-2009 Panels with Swisslog supported Nexus Panels, and providing Ethernet conversion

panels for all blowers and transfer units. A System Control Center and Cold Backup will be added

to reduce system downtime during a potential computer failure.

RATIONALE:

UNM Hospitals relies heavily on the pneumatic tube system for transfer of time sensitive labs

specimens and medication orders/prescriptions. The current system is at the end of life (over ten years

old), and is no longer supported for maintenance or parts. The upgrade to hardware will allow for

Swisslog customer support and improved maintenance of the system. During peak usage, the pneumatic

tube systems conducts up to 3,500 transactions per day. With the current system, wait times for

delivery of an item to its final destination may take up to eight minutes. With the addition of Zone 7

and 8, simulations are projecting that the average wait time will decrease to less than one minute.

PURCHASING PROCESS: The Architectural firm Studio Southwest was hired to provide design for the installation of Phase One

(Addition of Zone 7 and 8). Design documents will be submitted for bids using PRP (Price Request

Proposal) to On-Call Contractors. Phase Two will be procured utilizing Sole Source procedures for

awarding Swisslog to provide upgrade of existing Swisslog equipment.

FUNDING:

The total project budget is estimated at and will not exceed $950,000, $550,000 for Phase I and $400,000

for Phase II. Phase I $550,000.00 is to be funded by UNM Hospital Capital FY 2019 Renovation Fund.

Phase Two will be funded by UNM Hospital Capital FY 2020 Renovation Fund.

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October 26, 2018 UNMH Board of Trustees Meeting Minutes

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UNM Hospitals Board of Trustees October 26, 2018

Barbara and Bill Richardson Pavilion 1500

UNM Hospitals Board of Trustees Minutes – October 26, 2018 1

Agenda Item Subject/Discussion Action/Responsible Person

Voting Members Present Dr. Jerry McDowell, Ms. Christine Glidden, Mr. Terry Horn, Mr. Joseph Alarid, Dr. Aimee Smidt, Mr. Erik Lujan, Ms. Debbie Johnson, and Mr. Nick Estes

Ex-Officio Members Present

Dr. Paul Roth, Dr. Michael Richards, Mrs. Kate Becker, Dr. Jennifer Phillips, and Mr. Garrett Adcock

County Officials Present Mr. Clay Campbell

I. Call to Order A quorum being established, Dr. Jerry McDowell, Chair, called the meeting to order at 10:15 AM.

II. Announcements Dr. Jerry McDowell stated the Board of Trustees Meeting today timeframe has been reduced and he requested that administrative and committee reports be deferred until next month’s meeting unless there are any relevant issues due to The Joint Commission conducting their on-site visit this week.

III. Adoption of Agenda Chair McDowell requested a motion to adopt the agenda. Mr. Terry Horn made a motion to adopt the agenda. Ms. Debbie Johnson seconded. Motion passed with no objections.

IV. Consent Approval Mrs. Bonnie White presented the below identified Consent Items, which were discussed and approved at the Finance Meeting to be reviewed/approval by the full Board of Trustees (back-up documentation in BoardBook). Mr. Terry Horn stated the Finance Committee discussed both Consent Items and recommend approval by the full Board of Trustees.

Siemens Vision 600 PET-CT Scanner Endoscopy Expansion

Mr. Terry Horn made a motion to approve the Siemens Vision 600 PET-CT Scanner. Mr. Erik Lujan seconded. Motion passed with no objections.

Ms. Debbie Johnson made a motion to approve the Endoscopy Expansion. Mr. Terry Horn seconded. Motion passed with no objections.

V. Public Input No Public Input

VI. Approval of Minutes

Dr. Jerry McDowell requested a motion to approve the meeting minutes. Mr. Terry Horn made a motion to approve the September 28, 2018 UNMH Board of Trustees Meeting Minutes. Ms. Christine Glidden seconded. Motion passed unanimously.

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VII. Mission Moment Mrs. Kate Becker read an appreciative Tweet posting expressing gratitude for the people they met at UNMH – “…genuinely some of the finest human beings I’ve had the chance to meet – true stewards of compassion and kindness” “….if you are a nurse, if you know a nurse, if you want to be a nurse, you are forever a hero in my book”

VIII. Action Items N/A

IX. Board Initiatives Chairman’s Report: Dr. Jerry McDowell, Chair, reported that the Joint Commission has been on-site this week and he joined their Leadership Meeting this morning. Chair McDowell said he could not have been more pleased that the TJC members were glowing with the quality of the staff and that they told stories about their time and visit at UNM Hospitals. A great experience thanks to Dr. Roth, Dr. Richards, Kate Becker and every other member of the administrative team. Board of Trustees Election of Officers Policy: Dr. Jerry McDowell stated the Executive Committee has met and discussed Officers for this year and he has discussed their recommendations with Mrs. Kate Becker and Dr. Paul Roth, who concur. Chair McDowell said the recommendation from the Executive Committee is to continue with the same Officers; however, he asked if there are any other nominations from Board of Trustee Members. With no further nominations, Chair McDowell requested a motion. Conflict of Interest Management Plan: Dr. Jerry McDowell reminded everyone that the Conflict of Interest Management Plan was approved at the September Board of Trustees Meeting. Copies distributed to everyone for their signature and return to Fontaine Whitney for filing.

Mr. Terry Horn made a motion that the current Officers remain for another year. Ms. Christine Glidden seconded the motion. Motion passed unanimously.

X. Administrative Reports

No reports this month due to The Joint Commission conducting on-site visit.

XI. Committee Reports No reports this month due to The Joint Commission conducting on-site visit.

XII. Other Business September Financials reviewed by Ms. Bonnie White (dashboard in BoardBook)

XIII. Closed Session At 11:04 AM, Dr. Jerry McDowell, Chair, requested a motion to close the Open Session of the meeting and move into Closed Session.

Mr. Terry Horn made a motion to close the Open Session and move to the Closed Session. Dr. Aimee Smidt seconded the motion. Per Roll Call, the motion passed.

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Roll Call:: Dr. Jerry McDowell – Yes Ms. Christine Glidden – Yes Dr. Raymond Loretto – Not Present at Meeting Ms. Debbie Johnson – Yes Mr. Terry Horn – Yes Mr. Erik Lujan – Yes Dr. Aimee Smidt – Yes Mr. Joseph Alarid -- Yes Mr. Nick Estes – Yes

XIV. Certification After discussion and determination where appropriate, of limited personnel matters per Section 10-15-1.H (2); and discussion and determination, where appropriate of matters subject to the attorney-client privilege regarding pending or threatened litigation in which UNMH is or may become a participant, pursuant to Section 10-15-1.H (7); and discussion of matters involving strategic and long-range business plans or trade secrets of UNMH pursuant to Section 10-15-1.H (9), NMSA, the Board certified that no other items were discussed, nor were actions taken.

Vote to Re-Open Meeting At 11:20 AM, Dr. Jerry McDowell, Chair, requested a roll call motion be made to close the Closed Session and return the meeting to the Open Session.

Mr. Nick Estes made a motion to close the Closed Session and return to the Open Session. Ms. Debbie Johnson seconded the motion. Per Roll Call, the motion passed. Roll Call:: Dr. Jerry McDowell – Yes Ms. Christine Glidden – Yes Dr. Raymond Loretto – Not Present at Meeting Ms. Debbie Johnson – Yes Mr. Terry Horn – Yes Mr. Erik Lujan – Yes Dr. Aimee Smidt – Yes Mr. Joseph Alarid -- Yes Mr. Nick Estes – Yes

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Dr. Jerry McDowell, Chair, requested the Board acknowledge receipt of the following as presented in the Closed Session to acknowledge, for the record, that those minutes were, in fact, presented to, reviewed, and accepted by the Board and for the Board to accept the recommendations of those Committees as set forth in the minutes of those committees meetings and to ratify the actions taken in Closed Session.

August 24, 2018 UNMH BOT Quality and Safety Committee Meeting Minutes August 29, 2018 UNMH BOT Finance Committee Meeting Minutes September 19, 2018 Medical Executive Committee (MEC) Meeting Minutes September 26, 2018 UNMH BOT Native American Services Committee Meeting

Minutes Dr. Jerry McDowell, Chair, requested a motion be made to approve the Credentialing and the Clinical Privileges as presented in Closed Session:

The Board of Trustees acknowledged receipt of the following:

08/24/18 UNMH BOT Quality and Safety

Committee Meeting Minutes 08/29/18 UNMH BOT Finance Committee

Meeting Minutes 09/19/18 Medical Executive Committee

(MEC) Meeting Minutes 09/26/18 UNMH BOT Native American

Services Committee Meeting Minutes Mr. Nick Estes made a motion to approve the Credentialing and Clinical Privileges as presented in the Closed Session. Ms. Christine Glidden seconded. The motion passed unanimously.

Adjournment The next scheduled Board of Trustees Meeting will take place on Friday, November 30, 2018 at 9:00 AM at the University of New Mexico Hospitals in the Barbara & Bill Richardson Pavilion (BBRP) 1500. There being no further business, Dr. Jerry McDowell, Chair, requested a motion to adjourn the meeting.

Mr. Terry Horn made a motion to adjourn the meeting. Mr. Joseph Alarid seconded. The motion passed unanimously. The meeting was adjourned at 11:25 AM.

___________________________________________ Dr. Raymond Loretto, Secretary UNM Hospitals Board of Trustees

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MISSION MOMENT

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OUR MISSION MOMENT:WHY WE ARE HERE? THE BEST IN PATIENT CARE

MELA CHAPMAN, DNP, RN, NE-BC EXECUTIVE DIRECTOR: ADULT HOSPITAL INPATIENT SURGICAL UNITS

MOSCHELL BILLINGSLEY, MSN, RN-C EXECUTIVE DIRECTOR: UNMH PATIENT THROUGHPUT & FLOW

MICHELLE WAFER, MSN, RN, RN-C EXECUTIVE DIRECTOR: WOMEN’S HOSPITAL & NEWBORN NURSERY

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A TRAGIC STORY THAT LET US REMEMBER WHY WE ARE ALL HERE….

• In recent weeks, something very special and deeply touching occurred on our Adult Surgical unit, 6S.

• A female patient was admitted to the unit post-op., pelvic & femur fractures. On the outside, this was yet another MVC patient, not a patient uncommon to the nursing care provided by the staff of 6S.

• What was different about this trauma patient is that she had tragically lost her 2 month old baby in that MVC. The patient and her family were travelling through NM on their way back to their home-state Colorado. Mom had climbed into the backseat of the car to sit and breastfeed her infant child, when the accident occurred. 6S Staff were immediately struck by this fateful tragedy and rallied their nurturing care around their patient.

• Chaplain Ben had made a spiritual connection with the young mother and spent a great deal of time with her, helping her process through her bereavement. The day came when the infant child was to be transported by the funeral home to her final resting place in Denver. As any grieving parent, mom wished to see her baby one last time, before the funeral. Mom’s injuries were so severe, that she could not possibly be transported to the funeral home.

• The entire 6S team, supported by their Unit Director Allison Phillips and their Executive Director, Mela Chapman, started to process how they might facilitate a plan to bring the baby girl to 6S.

• Nicole, our House Supervisor and Mo Billingsley their Executive Director, worked on communications with the funeral home and made the arrangements for them to bring the infant to the unit for the following day.

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A TRAGIC STORY THAT LET US REMEMBER WHY WE ARE ALL HERE….

• The 6S consulted with Michelle Wafer, Executive Director over Mother Baby units. Michelle was an expert resource in these matters, as she and her team delicately manage these traumatic situations regularly.

• On the Wednesday morning, Michelle took charge and accompanied the funeral team and baby to 6S. With great care, Michelle swaddled the beautiful infant in blankets and presented her to the family now lining the room.

• The baby girl’s grandfather was the first to hold the little girl to his chest, while the family slowly started to process. This was a very moving experience for the entire staff on 6S. Their RN Supervisor for the day helped co-ordinate patient care in a manner that made it possible for the nursing staff and techs on the unit who had formed the closest bond with their patient, to remain in the room with her throughout that day.

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UNMH IS KNOWN FOR ITS’ REMEMBRANCE PROGRAMS:

IN THE WOMEN’S & CHILDREN’S HOSPITAL IT IS A PROGRAM CALLED

“RESOLVE THRU SHARING”

We prepared Mom and Family for the way the Baby would look and feel.

In addition to some quiet time holding her baby, Mom Michelle had brought with her molds to create foot and hand imprints for the family to keep and cherish.

The Family took pictures, and said their Blessings.

Our Chaplaincy provided spiritual aftercare (Code Lavender) for the unit in the days that followed.

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HSC Committee Update

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CEO Report UNM Hospitals

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MEMORANDUM

To: Board of Trustees From: Kate Becker Chief Executive Officer Date: November 30, 2018 Subject: UNMH Monthly Activity Update

The Hospital has been involved in a variety of activities and this report will focus on operations through October 2018. Quality: This section reflects data through September 2018 which is the latest data available through Vizient. UNMH continues the drive to improve overall quality and patient experience by focusing on items of low performance in the Vizient Quality and Safety report, specifically mortality and hospital acquired infection. For the month of September, six of the eight quality indicators remain at or better than the target level. Dr. Crowell will present details of the Hospital’s quality performance during the closed session of this meeting. Statistics (Financial data): As of the end of October the UNMH inpatient volume is lower compared to prior year. This effect may be due to the early viral season that was experienced in October of 2017. UNMH also continues to see a shift of patients from inpatient status to observation status. Patient days are 4% lower than budget in total with adult patient days accounting for a -2%, or -810 day, variance to budget. Adult equivalent observation days are up 29%, or 912 days from budget and prior year to date. Pediatric days are much lower at -8% to budget most likely related seasonality. Inpatient discharges are 5% lower than budget and slightly lower compared prior year activity. Outpatient activity is reported as 8% favorable for the month of October and flat compared to prior year. Emergency visits are 9% lower than budget but only slightly less than prior year. Case mix index remains greater than prior year and inpatient length of stay is flat compared to prior year. Financial: Net margin year to date is positive at $970,000. Net patient revenues continue on a positive trend while salaries, benefits and medical supplies continue trending over budget.

Strategic Planning: Management continues to make positive progress in partnering with Bernalillo County regarding the planning of behavioral health programs to improve access and diversify treatment options available to the community. Management will provide an update to the Board once the plans become more solidified.

Human Resources: The turnover rate rolling year to date is 14.97% for the full workforce and 13.97% for nurses as a subset. This represents a slight decrease over the last quarter results and meets the goal of 15%. Overall hiring is in pace with the current turnover rates. UNMH currently has 5983 employed FTEs which is 390 (6.11%) less than budget. The hiring rate of nurses and non-nursing staff continues to be stable however. Native American Liaison: Hospital management is working closely with I.H.S. and tribal facilities to coordinate on Medicaid claims that meet criteria for 100% federal match ‘FMAP’. Agreements have been signed with Albq Area I.H.S. and Navajo Area I.H.S.; they are in progress with Isleta and Jemez pueblos. Management concluded our annual consultative visit with NM Pueblos, Tribes and Nations in September 2018. Additionally we provided a guest update during the Albuquerque Area I.H.S. tribal consultation on November 20th. Inpatient census: 5,206 admissions, up 6% over prior year; 40,140 outpatient visits, up 1% over prior year. An area of focus for 2019 is improving access to scarce sub-specialty services for referred patients. Bernalillo County: Management has met with Bernalillo County and IHS leadership to discuss the execution of the most recent Memorandum of Understanding. As agreed in that meeting, a small working group will continue monitoring execution of the MOU. If there are any questions on this or other matters, please feel free to contact me.

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CMO Report UNM Hospitals

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To: Board of Trustees From: Irene Agostini, MD UNMH Chief Medical Officer Date: November 30, 2018 Subject: Monthly Medical Staff and Hospital Activity Update 1. The average wait time for a patient from the Adult Emergency Department to be placed after admission for

the month of October 2018 was 7 hours and 12 minutes. This is an improvement of 3 hours and 48 minutes from October of 2017 when the placement time was12 hours. UNMH remains at greater than 90% capacity.

We sent 40 patients to an SRMC Inpatient unit instead of placing at UNM Hospital. 2. The Community Partnership with Lovelace Health system continues to be successful in putting the needs of

the “Patient First”, allowing continued access to those patients that can only be cared for by UNMH. In the month of November:

94 patients were triaged from the UNM Health System to Lovelace inpatient units. 3. Our adult ALOS (average length of stay) for October 2018 was 6.98 with a FYTD ALOS of 6.76 compared to

October 2017 which was 6.99 for the month of October with a FYTD of 6.99.

Our length of stay index for adult patients in September 2018 was 0.92 which is lower than September of 2017 when it was 1.07 indicating the patients are receiving care in a more efficient manner. The CMI (case mix index) for adults for September 2018 was 2.30 which are higher than September of 2017 when it was 2.24 indicating we are caring for more complex patients. We continue to hardwire our new processes to decrease our ALOS despite accepting higher acuity patients.

4. Our “LEADing to Excellence” quarterly employee forums have wrapped up and we are preparing for our next

retreat that will occur on December 13th. Our key takeaway building blocks on our continued journey to Hardwiring Excellence include the following:

We are in this together, removing the “us” vs. “them” mentality

Critical Conversations, High/Solid/Low performers

Huron engagement and excellence journey 5. UNMH Surgical Services continues to build a solid foundational structure. This work of creating reliable

process to serve the needs of New Mexican’s has shown good results in the on-time start of operating room cases. In the month of October the UNMH main OR has a 60.8% on-time start of all cases, BBRP has a 69% and OSIS has a 67.5% on-time start.

The team continues to monitor and measure the time it takes to turn an OR room over (TOT) to be available for the next scheduled patient surgery. For the month of October the TOT was 59 minutes for the UNMH main OR and OSIS has a 33 minute TOT. The BBRP has begun measuring TOT by type of surgery performed. This is meant to align closely with equipment and personnel. We will continue to monitor and report this vital step in creating efficiency and safety for our patients.

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Finance,

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UNM HOSPITAL BOARD OF TRUSTEES

Finance Committee Meeting

Wednesday, November 28, 2018 11:00 AM

UNM Hospitals Administration, Large Conference Room

Objectives

Provide financial and human resources oversight of UNM Hospitals.

Finance Committee Meeting:

I. Approval of October 24, 2018 meeting minutes

II. Consent Items for recommendation for approval to full Board of Trustees

a. Disposition of Assets

b. Repair, Renew, Replace Capital Project – ACC Roof Replacement

c. Repair, Renew, Replace Capital Project – Pneumatic Tube System

III. Financial Update for the four months ended October 31, 2018

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Audit & Compliance

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UNM HOSPITAL BOARD OF TRUSTEES

Audit and Compliance Committee Meeting

Wednesday, November 28, 2018 1:00 PM

UNM Hospitals Administration, Large Conference Room

Objectives

Provide audit and compliance oversight of UNM Hospitals.

Finance Committee Meeting:

I. Approval of October 10, 2018 meeting minutes

II. CLA IT Assessment

III. Compliance and Internal Audit

Discussion – Related Party

Discussion – Compliance and Audit Committee Charter

Discussion – Compliance report from 10.10.18 meeting

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October Financials

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1

UNM Hospitals

FINANCIAL UPDATE

Through October 2018

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2

UNM HospitalYTD Stats Variance to Budget

October 2018

MTD Actual MTD Budget

MTD

Variance

MTD %

Variance YTD Actual YTD Budget

YTD

Variance

YTD %

Variance

Acute Discharges 1,816 1,939 (123) -6.3% 7,385 7,756 (371) -4.8%

Acute Patient Days 12,227 12,684 (457) -3.6% 48,857 50,737 (1,880) -3.7%

Surgeries 1,773 1,744 29 1.7% 6,785 6,976 (191) -2.7%

ER Visits 6,442 7,005 (563) -8.0% 24,505 28,020 (3,515) -12.5%

Primary Care Visits 17,119 14,942 2,177 14.6% 59,569 59,768 (199) -0.3%

Specialty Visits 32,821 31,133 1,688 5.4% 125,225 124,535 690 0.6%

0.6%

-0.3%

-12.5%

-2.7%

-3.7%

-4.8%

-15.0% -10.0% -5.0% 0.0% 5.0% 10.0% 15.0%

Specialty Visits

Primary Care Visits

ER Visits

Surgeries

Acute Patient Days

Acute Discharges

YTD % Variance

YTD % Variance

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3

UNM HospitalsExecutive Summary


UNM Hospitals Oct-18 YTD YTD Budget % Budget YTD Prior YTD % Growth

ALOS 6.92 6.83 6.77 -0.91% 6.91 -1.07%

CMI Adjusted Patient Days 60,623 238,511 211,362 12.84% 223,190 6.86%Net Core Patient Revenues ($ in thousands) 78,130$ 293,036$ 287,870$ 1.79% 281,512$ 4.09%Total Operating Expenses ($ in thousands) 94,230$ 367,534$ 358,969$ -5.25% 348,672$ -5.41%Net Operating Income ($ in thousands) (6,689)$ (34,330)$ (34,170)$ -0.47% (33,599)$ -2.17%Net Income ($ in thousands) 2,094$ 971$ 1$ 230$

Net Core Revenue/Adj Patient Day 1,289$ 1,229$ 1,362$ -9.79% 1,261$ -2.59%

Cost/CMI Adj Patient Day 1,554$ 1,541$ 1,698$ 9.27% 1,562$ 1.36%

FTEs 6,479 6,433 6,484 0.80% 6,240 -3.09%

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3,873 1.24%

4,531 38.52%

(2,687) (1.54)%

(3,190) (2.56)%

(1,557) 1.53%

970

-3,200 -2,200 -1,200 -200 800 1,800 2,800 3,800 4,800

Net Patient Revenue

Change in Net Assets

Other Revenue

Salaries & Benefits

Other

Med Service & Supply

UNM HospitalsBudget to Actual Variance


13

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UNM Hospitals Board of Trustees III. ADOPTION OF AGENDA ......Nov 30, 2018 · Belmonte, Jessica,...

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