April 1, 2025 at 1:00 p.m.
PROCEDURAL ITEMS:
Call to Order
Chairwoman Shawn Jeffrey called the meeting of the Miners’ Colfax Medical Center Board of Trustees to order on April 17, 2025, at 1:00 p.m.
The meeting was held at the Miners’ Colfax Medical Center Acute Conference Room at 203 Hospital Dr., Raton, NM.
Members: Shawn Jeffrey, Chairwoman- present, Loretta Conder, MD, Vice-Chairwoman- present, Roy Fernandez, Secretary/Treasurer- present ( virtual attendance), David Ortiz, Trustee- present, Zita Lopez, Trustee- present
Staff: Brian Roland, CEO, Barbara Duran, HR Director, Lonny Medina, CFO, Sarah Zmich, Recorder
Pledge of Allegiance & Salute to the New Mexico Flag
Chairwoman Shawn Jeffrey, led Trustees, visitors and staff present in reciting the Pledge of Allegiance and Secretary/Treasurer Roy Fernandez led the salute to the New Mexico flag.
Roll Call: Chairwoman Shawn Jeffrey- Yes. Vice-Chairwoman Dr. Loretta Conder- Yes, Secretary Roy Fernandez- Yes, Member David Ortiz- Yes, Member Zita Lopez- Yes.
Correction/ Approval of Agenda
The Board Members reviewed the Agenda for April 17, 2025.
Dr. Loretta Conder stated there would not be a Medical Staff Report due the absence of Dr. Jessica Roberts.
Vice-Chairwoman Dr. Conder, made a motion to approve the agenda as corrected. Secretary Roy Fernandez, seconded.
Roll Call: Chairwoman Shawn Jeffrey- Yes, Vice-Chairwoman Dr. Loretta Conder- Yes, Secretary Roy Fernandez- Yes, Member David Ortiz- Yes, Member Zita Lopez- Yes. Approved 5-0.
Correction/ Approval of Minutes
Member Zita Lopez made a motion to approve the March 21. 2025 minutes as presented. Member David Ortiz, seconded.
Roll Call: Chairwoman Shawn Jeffrey- Yes. Vice-Ch~1irwoman Dr. Loretta Conder- Yes, Secretary Roy Fernandez- Yes, Member David Ortiz- Yes. Member Zita Lopez- Yes. Approved 5-0.
ACKNOWLEDGEMENT OF VISITORS
Meghan Herman, Specialty Clinic Manager: Lee Ann Dominguez, RHC Manager; Rhonda Moniot, CNO; Barbara Duran, HR Director; Stephen Kelley, LTC Administrator and Rae Hager, Quality Director.
EXECUTIVE SESSION
ADJOURN TO EXECUTIVE SESSION FOR THE PURPOSE OF DISCUSSING LIMITED PERSONNEL MATTERS AS PER NEW MEXICO OPEN MEETINGS ACT 10- 15-1 (H) (2) OF THE OPEN MEETINGS ACT CONCERNING: Medical Staff Credentialing
Motion: At 1:02 p.m. Member David Ortiz, made the motion to go into Executive Session for the purpose of limited personnel matters pursuant to Section 10-15-1 (H) (2) of the Open Meetings Act. Member Zita Lopez, seconded.
Roll call: Chairwoman Shawn Jeffrey- Yes, Vice-Chairwoman Dr. Loretta Conder- Yes, Secretary Roy Fernandez- Yes, Member David 0. Member Zita Lopez – Yes. Approved 5-0.
This is a closed session for matters pertaining to Medical Staff Credentialing.
The Board of Trustees resumed to open session at 1:06 p.m.
MEDICAL STAFF PRIVILEGES AND APPOINTMENTS
Dr. Conder, informed the Board that one (1) provider was recommended by the Credentials Committee for new appointment in April: Christopher Nelson, MD-Tele-radio!ogy.
Motion: Member David Ortiz, mo ved to accept the Credential Committee’s recommendations as presented. Secretary Roy Fernandez seconded, a roll call vote was taken, and the motion carried.
Roll Call: Chairwoman Shawn Jeffrey- Yes, Vice-Chairwoman Dr. Loretta Conder- Yes, Secretary Roy Fernandez- Yes, Member David Ortiz- Yes, Member Zita Lopez – Yes. Approved 5-0.
MEDICAL STAFF REPORT
No Medical Staff Report was given during the April 17th Meeting due to the absence of Dr. Roberts.
DEPARTMENT REPORT
MCMC Clinic
Access to Care Project- Meghan Herman and Lee Ann Dominguez
Increasing Patient Numbers in the Clinic
Last Year’s PI Project- Returning Voicemail Within 1 Hour
Year long project tracked patient’s perception to their access to care with Press Ganey results:
- 1st Quarter: 20.0%
- 2nd Quarter: 33.37%
- 3rd Quarter: 54.5%
- 4th Quarter: 83.3%
Plan, Do, Study and Act
Plan: Expand access to care by increasing number of patients scheduled per day in the clinic
Do: Optimize appointment scheduling to reduce missed opportunities
Study: Track schedule data and calculate daily appointment percentages of each provider
Act: Implement checking schedules every morning and communicating available appointment times patients can be added/double hooked. Email providers with their statistics. Employment of Triage Nurse.
Plan
The objective of this study is to improve access to care which will assist in increasing overall patient satisfaction in the MCMC Clinics.
Patients depend on reaching clinic staff by phone to schedule appointments.
Quality of the clinic’s phone communication has a direct impact on the patient’s overall satisfaction and perception of their access to care.
GOALS
- Providers have a goal to see 2 patients per hour
- One hour of the day with be designated for administrative time.
- Providers in the clinic 8 hour/day will have a goal of 14 scheduled patients per day
- Providers in clinic 10 hour/day will have a goal of 18 scheduled patients per day
TIMELINE
Staff will document data everyday:
- Total number of scheduled appointments
- Total number of no shows
- Total number of nurse visits
- Total number of patients seen
- Total number of hours Provider in clinic
- Analyze Providers data percentages daily. weekly and monthly
CLINIC TEAM
- Primary Care- 6 providers. -l nurses and 4 techs
- Specialty- 4 providers. 3 nurses and I tech
- Data Analyzer: Dominique Romero
Do
Implement clinic nurses printing provider’s schedules every morning
- Check for appropriateness of appointments schedules
- Add notes for where acute appointments can be added or where patients can be double booked (i.e. nurse visits, annual visits – acutes added at end of visit)
- Goal is optimize appointment scheduling and avoid missed opportunities for adding patients.
- Schedules will be reviewed by clinic supervisor and then given to front registration
Front registration staff will be confident when adding on acute appointments when working with a written template.
Effective communication leads to decreased criticism and enhances clinic teamwork.
Clinic nurse techs compile date at the end of each day:
- Document total number of patients seen
- When a patient no shows nursing tech will call patients to offer rescheduling of appointment
- Tech will document in chart if able to contact patients, reason for no show and if patient chose to reschedule with date
- Nurse Tech will give Clinic Data Sheet to the nurse secretary to analyze at the end of each day
Providers will be emailed weekly with compiled data of percentages of patients seen and if weekly goal was met.
Offering data weekly as a visual to each Provider for transparency.
Reminder Phone Calls
- Ticket opened up with Cerner regarding reminder phone calls to patients
- Tested with multiple staff members on multiple occasions
- Continued having techs call and patients were saying they already received a phone call
Study
Variables to study:
Provider availability- Majority of Providers in clinic have a rotating schedule:
- Dr. Leonardo Lopez: Clinic every other week (2 weeks a month)
- Dr. Laith Salih: Clinic every other week (2 weeks a month)
- Sara Lark. NP: Clinic Monday-Wednesday every week
- Dr. Christine Lopez: Clinic 2-4 days a month
- Dr. Douglas Smith: Clinic Tuesday-Friday every week
- Dr. David Fairbanks: Clinic Monday-Wednesday every other week (6 clinic days/month)
Our Providers take on multiple roles within the hospital- Hospitalist, Pediatric Hospitalist, OB Labor and Delivery, and Surgery.
Front registration has been asked to confirm listed phone number. When phone number is wrong in chart the whole process of scheduling, confirming appointment and rescheduling fails.
Act
The MCMC Clinic will become more accessible to patients as clinic staff are actively working every day to increase availability for clinic appointments and meeting target goal numbers.
New Position- Clinic Triage Nurse
- Currently in clinic training and expected to be in her position at the end or April
- The Triage Nurse will be able to triage patients for same day appointments which increases access to care
- Emergency Room staff will be able to call the Triage Nurse directly for scheduling follow up visits to streamline process
Prescription Renewals
- Complaints from patients regarding prescription refills “Sent a refill request to your providers office with no response”
- Placed a ticket with Cerner
- Was able to follow two staff members prescription and one errored out from Mesa Pharmacy; researched and it was on Mesa’s side,
- Put our PR on Facebook to patients if they hadn’t received their prescriptions to call the clinic
DISCUSSION/ACTION ITEMS:
Policies & Procedures Review
The following policies have been reviewed and approved by the Miners ‘ Colfax Medical Center’s Board of Trustees:
- Set Up for PCA Infuser System Protocol
- Patient Controlled Analgesia Protocol
- Pain Assessment, Reassessment, and Management
- Patient Rights and Responsibilities
- Cardizem Protocol
- Octretide Protocol
- Drug Procurement-Inventory Control
- Supply Chain-Receipt of Sterilized Drug Products
- Stroke
- Pelvic Examination and Pap Smear
- Discharge Planning
- Screening. Brief intervention and Referral of Treatment
- Peak Census Plan
- Diprivan (Propofol) Drip
- Approved Policies On-Line
- Adenosine (Adenocard)
- After Hours Coverage
- Ancillary and Other Staff Responsibilities
- Annual Evaluation Committee and Procedure
- Biomedical Waste Plan
- Cash Receipts and Recordings Charges
- Changes to Rural Health Clinic Hours of Operation or Staff Hours
- Compliance with Federal, State and Local Laws and Personnel Summary
- Compliance with Location Requirements for Certified Rural Health Clinics
- Credit Policy
- Disclosure-Owner director, and Medical Direction
- Emergency Procedures-Drug and Biological for Common Life-Threatening Injuries and Acute Illness
- Financial Arrangements
- Handling and Dispensing of Drugs and Biologicals and Authorized Personnel
- Housekeeping
- Medication Recall and Patient Notification
- Non-Medical Emergencies
- Patient Consent, Procedures, and Authorization to Release/Obtain Medical Information
- Patient Scheduling and Triage by Phone
- Physician, Nurse Practitioner Absence
- Policy and Procedures Review Committee
- Preventative Maintenance Program-Equipment Inventory and Inspection
- Protection of Record Information on Clinic Premises
- Provision of Services
- Referrals, Agreements and Arrangements
- Removal of Expired Drugs and Biologicals
- Rural Health Clinic Lines of authority and Organization Chart
- Rural Health Clinic Non-Discrimination Statement
- Staff Respons ibilities-Medical Director/Physician Member
- Staff Responsibilities- Physician Extender
- Statement of Compliance and Approval
- Statements and Collections
- Storage of Drugs and Biologicals
- Termination of Care
Motion: Member David Ortiz moved to accept the approval of the Policies and Procedures presented. Secretary Roy Fernandez seconded, a roll call vote ¼as taken, and the motion carried.
Roll Call: Chairwoman Shawn Jeffrey- Yes, Vice-Chairwoman Dr. Loretta Conder- Yes, Secretary Roy Fernandez- Yes, Member David Ortiz- Yes, Member Zita Lopez – Yes. Approved 5-0.
FINANCIAL REPORT
The Board of Trustees was presented with an update from Lonny Medina, CFO:
- $8,223,252 in cash
- 73.7 days of cash on hand
- Net patient revenue YTD $18,310,797
- Actual cash received from patient services YTD $22,103,836
- Surgical Cases YTD 73
- LTC admission YTD 9
- Observation admissions YTD 248
- Clinic admissions YTD 8,782
- ER admissions YTD 3,610
- Births YTD 31
- MCMC Land Grant Permanent Fund Balance $192,0 I 8,772
The two HY AC units are currently being installed and the payment of S580,000 will have to be made within the next month.
The new CT scanner is in operation and the payment of approximately $500,000 will need to be made once the final installation work is completed.
Key Dates:
- 4/15/25 SB161 Bridge to HDAA Report & Payment Request- S312,500
- 5/1/25 Operating Budget Submission to DFA- S43,684,000
(Includes 4% pay rate increase; waiting for DFA budget on longevity & 80% health and liability insurance increase)
- 5/31/25 HDAA Revenue Received- Quality Incentive CY24- $1.4 million
ADMINISTRATOR’S REPORT
Brian Roland, CEO gave a brief update to the Board of Trustees on the month of March:
A legislative update will be provided at the May Board of Trustees after the New Mexico Hospital Association session on April 28th.
Work continues to find mammography funding and services for MCMC.
The contract to update the peer review process with an outside source is in the final stages of approval.
The final steps lo complete the installation of the new CT machine are near completion.
UPDATE TO CARES CHAMPION
Work continues on revamping the CARES Champion program at MCMC.
FACEBOOK LIVE STREAMING ENDING NOTICE
Notice was given at the April 17 MCMC Board of Trustees Meeting that the meetings will no
longer be recorded or streamed live on Facebook. Future Board meetings will be in-person only.
EXECUTIVE SESSION
ADJOURN TO EXECUTIVE SESSION FOR THE PURPOSE OF DISCUSSING:
LIMITED PERSONNEL MATTERS PURSUANT TO SECTION 10-15-1 (H) (2) OF THE OPEN MEETINGS ACT.
MEETINGS SUBJECT TO THE ATTORNEY-CLIENT PRIVILEGE SECTION 10-15-1 (H)(7) OF THE OPEN MEETINGS ACT.
Motion: At 2:12 p.m. Member David Ortiz, made the motion 10 go into Executive Session for the purpose of the discussion of matters pursuant to Sections 10-15-1 (H) (2), 10-15-1 (H)(7) and 10-15-1 (H)(9) of the Open Meetings Act. Secretary Roy Fernandez, seconded.
Roll call: Chairwoman Shawn Jeffrey- Yes, Vice-Chairwoman Dr. Loretta Conder- Yes, Secretary Roy Fernandez- Yes, Member David Ortiz, Member Zita Lopez – Yes. Approved 5-0.
This is a closed session.
The Board of Trustees returned to open session at 3:32 p.m.
ADJOURNMENT
With no further business and no action taken, a motion was made by Member David Ortiz, with a second from Secretary Roy Fernandez, to adjourn the Board of Trustees Regular Meeting.
The motion carried, and the Board of Trustees Regular Meeting adjourned at 3:35 p.m.
Roll Call: Chairwoman Shawn Jeffrey- Yes, Vice-Chairwoman, Dr. Loretta Conder- Yes, Secretary Roy Fernandez- Yes, Member David Ortiz- Yes, Member Zita Lopez – Yes. Approved 5-0.
Attest:
Shawn Jeffrey, Chairwoman on May 16th, 2025
David Ortize, Member on May 16th, 2025