BOCC Special Meeting 03/07/08 Print
Board of Commissioners - Minutes






Chairman Larry Ammons convened a special meeting of the Haywood County Board of Commissioners at 1:45 p.m. in the Board Room in the County Commissioners’ Meeting Room at the Haywood County Justice Center, Waynesville, North Carolina, with members Vice-Chairman J.W. “Kirk” Kirkpatrick, III, Commissioners Mary Ann Enloe, Charles “Skeeter” Curtis and Bill L. Upton present. Staff members present were County Manager David B. Cotton, Assistant County Manager Marty Stamey and Administrative Assistant Rebecca Morgan.


Pledge of Allegiance


Chairman Ammons led the Pledge of Allegiance.


Chairman Ammons offered the invocation.


Receive Oral Report from the Compass Group and Haywood Regional Medical Center


Al Byers, Interim Chief Executive Officer (CEO) for Haywood Regional Medical Center (HRMC), approached the Board. Mr. Byers stated that the Hospital Board and Administration of HRMC are very concerned about the healthcare of Haywood County and have implemented a plan to resolve issues regarding HRMC and the termination for accepting Medicaid / Medicare insurance. Mr. Byers explained that staff of HRMC has been working diligently in an effort to assess issues regarding the hospital and to prepare an action plan.


Kate Fenner, Phd., with the Compass Group approached the Board. Dr. Fenner explained that this week there has been a rigorous assessment of HRMC. This assessment has given the Compass Group their initial observations of areas needing improvement.


Dr. Fenner presented a report with two portions. The first portion was a summation of the DFS report concerning their evaluations of the deviations from standards that resulted in the revocation of the Centers for Medicaid and Medicare services (CMS), which provide funding, through approval of the hospital with a provider number.


Dr. Fenner explained that the first focus was the governing board of the organization. Whenever there are significant issues regarding compliance with conditions of participation, the governing board is generally cited. It is expected that the governing board would have information regarding the procedures. The governing board was cited for failure to insure needs of patients by failure to insure systems in place to protect a variety of things such as patient rights, quality improvement, and organized nursing service. The second area that was cited was restraint. There are very strong standards regarding necessary times when a patient can be placed in restraint.  The next area that was cited was an area called patient grievance process, which allows every patient the right to complain about care they received. The institution has an obligation to respond to the patient’s complaint within a reasonable period of time. HRMC has chosen a time period of four days responding to grievances. The Federal standard from CMS is seven days to respond. The medication administration process includes how the medication is ordered by a physician, to what medication, the dosage, through how the pharmacy draws up a medication, how it is delivered, how the nurses administer it, how the nurses document it, and how the nurses assess the response to the patient to the medication. One citation was on assigning competent staff involving a medication error around three nurses and the failure to educate the nurses on that medication. Dr. Fenner explained that within hospitals there is a quality assurance performance improvement process. Every hospital that is approved in the United States is expected to have a sophisticated system for gathering data, analyzing data, spotting trends, and being able to respond to those patterns. The quality assurance program at HRMC is basically broken. There is a great deal of data collected, but the data is not converted into information and used in an effective way to correct practices. Nursing service was also cited. Many of the issues in nursing service were related to medication administration and infection control. Many of these are related to supervision and education issues. The area of equipment and supply maintenance were cited. An additional area of concern was pharmaceutical care which relates to the failure to monitor medication errors, aggregate them and look for patterns or trends, a lack of communication between the pharmacy and nursing. One area of concern in the report was respiratory care and staffing. The last two areas of concern were in infection control and in-patient post anesthesia evaluation.


Dr. Fenner shared that the Compass Group staff has been conducting a series of evaluations around the organization. There are five real systems issues that were found. The first issue found is the failure of leadership. The hospital board’s role and responsibility for stewardship in hospital operations is undeveloped. Dr. Fenner stated that the previous CEO did not provide board orientation opportunities. Therefore, the board has not known what to ask for and when to demand it. Information from and to the board and interaction with the board were strictly controlled so that people were not permitted to talk to board members without going through the CEO. This was on threat of termination. There has been an atmosphere of intimidation and control and some feared job security.


Secondly, there has been a failure of clinical leadership. The previous chief nursing officer committed to many appropriate actions in response to the first CMS survey. However, she failed to follow through on the same. Managers and directors were neither prepared nor appropriately supervised in the management responsibilities. Dr. Fenner explained that the performance improvement and quality assurance program is under the oversight of the Chief Medical Officer (CMO) and he has failed to effectively lead that initiative in a way that it would have its intended outcomes. The CMO was tremendously controlled and managed in terms of information flow by the previous CEO.


The third area discovered in the assessment was that the medical staff has not been sufficiently involved in performance improvement activities. The medical staff has not provided sufficient oversight of clinical care because they have been asked not to. Dr. Fenner stated that it is believed information going to and from medical staff has been manipulated. There has been an ineffective dialogue with hospital leaders and managers of the medical staff and there has been an inappropriate insertion of administrative control in issues that are really medical staff governance.


The fourth area is communication.  Dr. Fenner shared that communication was tightly controlled and monitored. People have been afraid to talk with one another. Dr. Fenner stated that this was to prevent any external scrutiny and to prevent internal punishment, or risk thereof.


Finally, the subtotal of all of this goes to the subject of mission. The organization as a whole has lost sight of its primary mission in patient care. The culture has developed into one into which people look out for their personal agendas.


Dr. Fenner stated that there is some fine staff at HRMC. The task now is to rebuild the house because there has been major damage done to the foundations.


Vice-Chairman Kirkpatrick inquired as to the plan of action.  Dr. Fenner replied that there are two tracks. The first part of the work is consultative, where they are helping the organization put together teams of staff, physicians, and other leaders in the organization, to address the CMS issues. Those issues must be addressed rapidly.


The second part of the work is interim executives. The Compass Group has identified strong people who will come and serve in an interim role. There is an interim chief nursing officer starting on Monday, March 10th. Presently, there is someone serving as an emergency room director and an implementation and compliance person. These interim executives will accelerate the learning curve and change the communication and the culture.


Commissioner Upton inquired as to the nurses and the specific actions needed to be performed. Dr. Fenner stated that the Compass Group has instituted, with the help of the current leaders, a medication supervision plan where there is not a medication passed in the hospital that is not double supervised by another senior experienced nurse. There will be intensive staff education development that will be very much welcomed by the nursing staff. Policies and procedures must be created that meet their environment and that stay steady. Dr. Fenner stated that when this process is completed, the staff will know clearly what the procedure is and how to do it.


Commissioner Enloe asked about the situation with the traveling nurses. Dr. Fenner stated that at this time traveling nurses are only in the emergency department and working with the interim emergency director.


Commissioner Curtis inquired as to the ratio of the nurses and patients and how are nurses trained without the patients in the hospital. Dr. Fenner replied that there is plenty of work to do, training to be conducted and educational programs that need to be attended. Commissioner Curtis inquired as to the timeframe for restoring the Medicaid and Medicare funding. Dr. Fenner explained that the process requires that all the deficiencies discovered by the surveyors be addressed first. Once the deficiencies have been addressed the hospital board and Mr. Byers will request a partial survey. There will be another thirty days for a complete survey of all conditions of participation. On the last day of the complete survey, HRMC would become eligible again to receive Medicaid and Medicare funding. Dr. Fenner stated that those timeframes could be pushed up from the initial expectation. 


Vice-Chairman Kirkpatrick inquired when CMS returns, what do they look at and how do they determine compliance. Dr. Fenner stated that CMS returns twice. At the initial return, CMS will look at the specific items they identified as needing improvement in their report. If they see that the items have been addressed they will return upon request, for a full survey. The full survey will look at everything. Dr. Fenner stated that most of the operations at HRMC are in compliance.


Vice-Chairman Kirkpatrick asked how CMS checks the processes. Dr. Fenner answered that CMS will review new records of the patients that have since been admitted. CMS will look at policies and procedures and data aggregation around quality improvement. They will interview nurses and medical staff.


Chairman Ammons read a letter received from Dr. Nancy Freeman. The letter stated that Dr. Freeman was resigning as the Chairperson of the hospital board.


Chairman Ammons stated that interviews for the hospital authority board of commissioners were conducted several months ago by the Board of County Commissioners. At that time, Dr. Henry Nathan was interviewed, and received the next highest amount of votes.


Commissioner Enloe made a motion to appoint Dr. Henry Nathan to fill the unexpired term of Dr. Nancy Freeman as a member of the hospital board. Vice-Chairman Kirkpatrick seconded. County Attorney Killian requested time to research the issue of hospital board of commissioner membership. The motion carried unanimously.


Commissioner Enloe requested that the hospital be a standing agenda item on every meeting until this is resolved. Chairman Ammons confirmed that this item would be on the agenda for all future meetings until the issue involving the hospital could be resolved.


Commissioner Upton expressed the importance of information and having it available to the public as quickly as possible.


Commissioner Curtis agreed that the hospital should be a standing agenda item and added that a representative from the hospital should be in attendance for the report.


Chairman Ammons requested that David Cotton, County Manager, add the hospital for notification of the meetings. Mr. Cotton confirmed that the hospital would be notified.


Chairman Ammons requested the Board to authorize him to draft a letter on behalf of the Board to the financial institutions asking that as part of their Community Reinvestment Act Plan to give some leniency on loans that medical practices may have. After discussion the Board agreed that Chairman Ammons would write a letter on letterhead to the financial institutions on behalf of the Board of County Commissioners.


Chairman Ammons requested that Mark Clasby call a special meeting of the Economic Development Commissions (EDC) Board and investigate ways to help all these businesses, the medical practices throughout the community and report back the Board of County Commissioners. 


Vice-Chairman Kirkpatrick requested a report from the hospital board authority of commissioners on the options for the hospital. The report should include hospitals that are interested in any type of mergers, collaboration with hospitals or management companies. Vice-Chairman Kirkpatrick stated that he would like to see the hospital return as the hospital. However, the financial situation could be depleted and other options need to be reviewed presently. Also, Vice-Chairman Kirkpatrick requested that the Chief Financial Officer at HRMS provide the Board of County Commissioners an analysis of the finances going into the future which assumes that the hospital is back in place within sixty days.  Vice-Chairman Kirkpatrick stated that a guideline for a financial situation for the hospital is important.


Commissioner Upton agreed that waiting is not an option. It is imperative that all the options for the hospital be reviewed. Commissioner Enloe inquired as to the time line for the report. Vice-Chairman Kirkpatrick replied that the report should be presented within the week. Commissioner Enloe confirmed that with the standing agenda item for the Board meetings, the oral report should include the financial status for the hospital. Chairman Ammons agreed that the report on the financial status is important, but the priority is the recertification. Chairman Ammons clarified that we want the financial report as long as it does not interfere with the primary issue of the recertification.


After discussion the Board agreed to schedule a special meeting on Friday, March 14th, at 1:45 pm.


Commissioner Curtis agreed that the primary focus is on recertification, but there are pressing issues concerning the hospital and its future. Commissioner Curtis stated  that Vice-Chairman Kirkpatrick could serve in the capacity mentioned to raise the necessary questions in an effort to resolve financial issues as soon as possible. Commissioner Enloe shared her approval for Vice-Chairman Kirkpatrick to act in that capacity. Vice-Chairman Kirkpatrick stated that he will discuss this issue with David Cotton, County Manager and have Mr. Cotton approach the hospital board. Commissioner Enloe stated that one question she would like answered is if all the $21 million could be spent, or must it be spent for what some of it was appropriated for which was the surgical center.



Public Comment Session


Chairman Ammons opened the public comment session. Comments are generally limited to three minutes per individual, unless the speaker is representing a group for which the comment period may be extended to five minutes.


Robin Tindall Taylor approached the Board. Ms. Taylor presented copies of the executive summary of the entire report available as well as a statement from Al Byers concerning his introduction at the meeting today at noon. 




Commissioner Enloe made a motion to adjourn. Commissioner Upton seconded and the motion carried unanimously. The time of adjournment was 2:40 pm. The DVD is attached by reference to the minutes.  


David B. Cotton                                                   Larry R. Ammons                   

Clerk                                                                   Chairman