 Good morning to all of you. My name is Jessica Holmes and I'm currently serving as the interim chair of the Green Mountain care board So today is day two of our Green Mountain care board hospital budget hearing process Just as a reminder. I said this on Monday, but I'll say it again today I'll say it the start of every Hearing day that we have to conduct our analysis and ultimately make a decision for each hospital We have to look to our statute and our hospital budget rule for guiding principles Our review requires us to balance several often competing factors For example, they need to slow the growth and health care expenditures while also ensuring that our hospitals have the resources They need to recruit and retain health care workers and provide the high-quality care we expect in our communities As we're looking to balance, you know, these competing factors of cost containment access quality and health system Sustainability we have to be mindful of this year's unique circumstances And the significant headwinds that we're facing. We have historically high inflation rates work for shortages and the continuing impacts of COVID-19 So both nationally and in Vermont. We're seeing hospitals facing unprecedented financial challenges as our businesses families and individuals. So What lies before us is not easy I think we all know that our short-term task is to set fiscal year 23 hospital budgets for the 14 community hospitals and we have to do this by September 25th. I mean September 15th. Sorry With that said, I want to remind everybody that the board is working closely with the agency of human services to begin the work that outlined in Act 167, which aims to move us closer to a sustainable hospital system That's going to ensure better ensure that Vermonters have access to high quality affordable care That longer-term work is going to involve extensive data analysis and community and hospital engagement to identify Options for a more sustainable path forward. So as we return to the task at hand I want to extend a thank you to each of the hospitals presenting today for the time and effort taken to submit the documents for our review There's a few housekeeping notes for today The presentation is a public meeting. It's being recorded and transcribed. There will be a publicly available record If any hospitals leadership believes that there's confidential information that the Green Mountain Care Board should consider Either as part of the hospital's presentation or in response to board or staff questions Please alert us before responding if needed the Green Mountain Care Board has the ability to go into executive session To review confidential information from hospitals I just want to note though that executive seven sessions are limited in scope as Provided by the open meeting law and they're limited to information such as contracts and information that would be considered Confidential under the Public Records Act. So if an issue of possible confidentiality arises I'll call on the board's legal counsel to determine the scope of what could be discussed in executive session And if deemed appropriate and at the appropriate time, I'll ask the board member for a motion For us to go into that executive session So knowing we have a really tight schedule today. We have three hospitals that we want to hear from I'm gonna hold all board and staff questions until the end of each hospital's presentation Northwestern is your entire team here? Everybody. Yes, we are Great. Okay. Well, welcome Hospital number three for the day. I appreciate you coming and All the work you've done in advance to prepare for this presentation and submit all the materials I know what a lot of work that is So it's very much appreciated from all of us and Jonathan from one interim to another interim. I appreciate what you've taken on Thank you and likewise So knowing we have a tight schedule here, I'm gonna hold all the board and staff questions until the end of your presentation And the hope is that we will be able to wrap up your presentation by four That's the schedule that we have so and then we will have some questions after that Russ McCracken our wonderful legal counsel. Can you please swear in all the witnesses that will be presenting today from Northwestern? Great. Yeah, happy to this is Russ staff attorney with the board For the Northwestern team can ask who Is going to be speaking this afternoon? So for us that will be myself Jonathan Billings Jake Holsheider our board president Pam Parsons community partner from Notch Stephanie bro chief financial officer Dr. John Minnedale our chief quality and medical officer and Potentially answering questions as we go Devon Batchelder our director of budget and Decision-making All right, terrific. Well, let's swear everybody in we can do it all together if you'd raised your right hand Do you solemnly swear that the evidence you shall give relative to the cause now under consideration? Shall be the whole truth and nothing but the truth so help you God I do Great. Thanks so much and The first time you speak if you could identify yourself by name that would help a lot with the Transcription in the court reporter and So with that I will turn it back to you chair Holmes Great, and I will pass the baton on to you all at Northwestern. I Can see your slides. So that's a good start. Excellent. Good Thank you very much. We appreciate this time to Present to you today I'm Jonathan Billings. I am the chief operating officer at Northwestern Medical Center and currently serving as the interim chief executive officer for the hospital Pleased to be with you today pleased to be joined by four Colleagues who will be sharing in the presentation two from the hospital senior leadership team and two from our community and so I would invite those folks to Introduce themselves We'll start with Stephanie Good afternoon everyone, I'm Stephanie bro, and I am the CFO and Dr. Minnadeo You appear to be on mute Okay, not a good start apologies John Minnadeo. I'm Mercy medicine doc here for most of my career and for the past three years the chief medical and quality officer and Jake Hi, my name is Jake Holsheider. I'm the nmc board president. Thank you And Pam hi, Pam Parsons executive director of notch northern tears Center for Health FQHC in Franklin and north northern Grand Isle and Devon hi Devon batch elder decision support and budget manager here at Northwestern Medical Center Thank you, and I would like to give Devon and his Team in fiscal great credit for the budget package that you have before you today That team does tremendous work in this and we deeply appreciate it I would also thank the gremant care board members and the gremant care board staff for the effort that all of you put Into this process We appreciate your work as well and with that I'll invite Jake our board chair to open our presentation with brief remarks Thank you very much Jonathan as I indicated my name is Jake Holsheider, and I am the current nmc board chair Just to kind of reiterate just a little bit about what share homes was started with I just want to recognize that We have a we have a really strong leadership team at the hospital and we're fortunate to have Jonathan and the rest of the team to help and To lead our team confidently without missing any beats as we look for a new CEO So we feel very fortunate to have such a strong team And to be able to have an interim Within the organization to step up for us during during this time. So I'd like to start with that And then as the board chair, I just like to summarize Three areas before we get going one is Obviously we we ask that you approve our budget as submitted the the budget we feel complies with the green mountain care board's guidance and the budget Results in a modest 1% operating budget To we're excited to share with you our high reliability journey what it means for our community hospital and ultimately becoming a CMS five star rated facility And then three We believe that we have a strong future at NMC and the pandemic and continual demand Proves the need for a strong community hospital in the St. Albans and Franklin County area We appreciate the opportunity to be here today and Jonathan I'll hand it back over to you and the team for the meat and potatoes of our presentation. Thank you Thank you, Jake We'd like to to move forward with providing Some of the crucial pieces of context that shape our budget request this year The first of these is The trended history of NMC's operating margins Our projections for fiscal year 22 Put NMC's net operating margin as negative for the fifth time in the past six years That is not a sustainable pattern For 22 our expenses are essentially on track except for our investment in travelers Our revenues are essentially on track and so We are you will hear throughout the presentation of our focus on restoring our workforce and Returning travelers to being an emergent stop gap as opposed to a reliant way to provide health care Our 2023 budget As you've seen as jake mentioned Puts our target for this graph at a positive 1% margin And i'll tell you that that feels ever so slim given all of the volatility that we face Long term a not-for-profit community hospital should have an operating margin around 3% to be sustainable And it is our goal to get there However, this year as we looked at all of the factors involved Including affordability access, etc We felt 1% was the margin that was proper to bring forth The next piece of critical context that I want to talk to you about is hospital capacity 30 out of 30 days in june NMC boarded patients in the emergency department either awaiting inpatient admission to our Progressive care unit that would have been full at 34 patients at that time Or boarded patients awaiting mental health placement Elsewhere in the community in the state And so that's very challenging for our emergency department We've seen a significant increase in sub-acute patient days given challenges with finding proper placement for patients We've gone so far as to have to cancel elective surgeries in october and then In june due to a lack of available inpatient beds. That's not staffed beds. That's available mattresses Our inpatient units have been consistently full Um And we have had as many as 11 patients Boarding awaiting placement or admission In an emergency department that has 14 formal rooms And we've had as many as 12 patients on our 34 bed inpatient unit Awaiting acceptance at a local nursing home And so the challenges are real and we live them every day And i'm going to pause for a moment and talk to you about my weekend I was administrator on call this sunday. We had 43 patients for a 34 bed unit Only one of those was covet positive Our day was complicated because we had staff out on covet but only one of our medical inpatients was covet positive Four were in the icu four were step down level 14 were med surge 12 were sub-acute waiting placement Seven others were boarding in the emergency department One of whom was intensive care unit level that we could not move to our inpatient unit And two were med surge level that were housed upstairs in our family birth center We had to call in extra staff paying double incentive We had staff who were on stay late We had a family birth center nurse float to the emergency department to care for three of the medical inpatients Our charge nurse took a full assignment We increased our ratios Both our pcu director and our chief nursing officer Took charge nurse duties that day And i helped with trash and linen to help housekeeping keep up It's not an unusual day for us. It's not every day, but it is not an unusual day for us Our local nursing home struggle and cannot take patients on friday saturday or sunday And this drive drives up length of stay for patients Because essentially if you have not been transferred to a nursing home thursday afternoon You're not going till monday afternoon and those are just extra days in the hospital Other vermont hospitals including our tertiary care center have experienced similar capacity issues and so transferring patients has been A significant challenge. We recently transferred A very concerning critical infant to manchester new hampshire Because all of the closer nick use were full And so we literally sent an ambulance to to manchester Our sub acute patients with complicating factors can be housed with us for months We have one individual Who is awaiting sub acute placement who has now lived with us for 237 days Without a facility being willing to accept that person Our mental health For inpatients continue to take days or weeks depending on the situation elsewhere in vermont And i will go out and opine that Um What i have just described to you and what our staff is living every day completely defies the consultant report That you have heard previously that placed nmc as a 70 bed licensed hospital rather than a 34 bed inpatient hospital And considered that we had too many beds And that report was referenced once again on statewide radio and a recent npr Um Sorry, and it gives our community a completely Unrealistic picture of what capacity is when we stand here at over capacity And staff if you'll jump to our the feeding right into this is unprecedented workforce challenges And on the screen you'll see a number of strategies that we're using To try and meet our workforce needs to keep up with patient care And their strategies at every hospital in vermont and every hospital in the country are also using at the same time You'll see that our traveler projection for 2022 was 10.2 million At the time we made this budget Um, it has since grown that projection to 11.2 million It is the single most threatening thing for nmc In the short term But we rely on those travelers at this point as we work to Restabilize the work the nursing workforce in vermont and at nmc We have hired a new chief human resources officer And he is here to lead us in the reimagination of our retention and our recruitment efforts Um, we have a tremendous partnership with ccv and vermont tech that is growing nicely And is full this year in both of their classes for nurses So we are working hard to grow our own And a point I want to make is that the issue goes well beyond nursing. Um We need lab techs. We need ultrasound techs. We need other diagnostic imaging professionals We need housekeepers We need folks to work in our food services department Um, this morning I had another conversation with an evs worker Who envisions a program with the state that connects us with higher ability And maybe ccv and with state programs to help with child care and transportation Because he feels there are people out there that would like to work but who have barriers in their lives And if we could help them pass the barriers that they would love to work full-time at nmc And so uh luke werner speaks passionately about it and he's Meeting with myself and ryan hamill our new chief uh human resources officer next week to dig deeper into this Um, but workforce challenges are something that impact Capacity and access every day for us and our folks are tired And then there's nmc strategic plan as um the final kind of shaping piece that i'll share with you nmc strategic plan is pretty straightforward. Um, it's three areas of focus This was developed by the nmc board of directors in collaboration with community partners With community input through our community health needs assessment And with our medical staff And it's three areas of focus quality and safety We need to achieve zero preventable harm and sustain zero preventable harm Jake talked about becoming a five star cms Uh facility our community deserves that level of quality. We will get there Financial sustainability Our strategic plan is to keep care local by enhancing core services Achieving operational effectiveness and supporting effective community partnerships Tremendous amount of focus in that area as we go forward And then a hospital is truly about people and so our third area strategic focus is engagement It's fostering a culture which inspires and engages our people and our community And that's our plan. That's our path forward. Um, It is my charge from our board to maintain progress in these three areas and we're intentionally Recruiting a new ceo who will lead us forth in this direction that shares this vision Of an exceptional community hospital that can earn a leapfrog a and that can earn cms five star So that's where we're headed and to expound a little bit on our work around quality and high reliability Um, I'd like to turn it to dr. John minnadeo our chief medical quality officer Thank you, jonathan In 1977 the tenor reef airport in the canary islands was the site of the deadliest commercial airline Disaster in history and that turned out to be a tipping point It was not only was a tragedy on that day, but it was an existential threat to the industry because if people didn't feel safe getting on an airline Um, there wouldn't be business. Um, so they recognized they needed to change their processes and they needed to change their culture So they embarked on that and they embarked on that with what we now look back on as the principles of high reliability How do you do something in a complex organization with? Um, where small errors can result in catastrophic, uh outcomes Reliably over and over and over again in a safe manner. And so what they found is they flattening the hierarchy of of communication promoting safety empowering staff to raise concerns empowering, uh, um Them to take action and stop the stop progress. Don't proceed in the face of uncertainty. Um, and so they They used and developed tools such as the famous checklist that we always hear about They standardized, uh, their their, um Approach to processes no longer was it relying on merely the pilot to to defer to all the decision making and it's resulted in a dramatic Change if you look at the data over the course of the decades to where, um, it's considered to be the safest mode of public transportation and so, um How does that relate to health care in 1999? Uh, institute of medicine, um Published to error as human which was uh dramatic at the time It estimated about 100 000 lives are lost every year to medical error in the united states That turns out to be that was an underestimate So that should have been our tipping point to, uh, adopt these processes, but we've been slow as an industry Uh, to date only about 25 of hospitals are embarking on The high reliability journey Dr. Chason, uh, the of the joint commission Has stated that the most successful hospitals have three things. They have leadership's commitment to zero preventable harm They have, uh, develop a commitment to develop a culture where it's safe to raise concerns and to and to surface, uh errors and to Then the the final thing is to have a robust process improvement So that we can learn from those errors and those errors aren't compounded or repeated We in our orientation for every new employee have an introduction to high reliability and within the first three months We require them to, um, attend a formal didactic two-hour training Um, and then on our annual refreshers every year. We have another, um, set of slides that Reminds us of, uh, the culture that we aim for and the tools that, uh, We want to standardize and embed in our culture And the next slide we'll show, uh, I just want to orient you to this. This is we talked about process, uh, process improvement We believe that the best people to know their processes and where things need to be are the frontline people And so this is an example of boards that are on all of our units that are designed for continuous process improvement And i'll just walk you through from left to right. There are different sections of the board The stoplight vertical section there, um, is a way for frontline staff to surface any concerns they have And they might be safety concerns. They might be operational concerns We promote having briefs at the beginning of the shift where the team gets together and talks about any safety issues challenges for the day goals of the day And then a debrief at the end of the shift where they can go over what went well But also where are our opportunities? What workarounds did we have to, um, Employ today? What what equipment is not working? What processes need to be looked into and they put suggestions or concerns up in that red section That alerts the director or manager of that unit when they come in To know what their what their staff is facing and what their concerns were And the goal is to within three days To to communicate on those little slips what their actions are and they move that down into the yellow So the staff knows that their their concerns are being addressed and how they're being addressed And then ultimately when they feel that that, um That concern was fixed they put it in the green And we like it to stay in the green for at least 30 days so that we know that the fix was sustainable And then once a month two of the executive Leadership team members around on each of these boards and talk with the staff and we look at those ones in green and say Looks like this was fixed. Do you really think so? Does everyone agree and if they do they get a gold star and that gets logged in a book and comes off So it staff can then see that their concerns are being dressed when they raise something It's being taken seriously and it's it's resulting in a better working environment If if uh, they may say that they're not, you know, it was fixed for a little while But now it's back again, and then we we put that back up in the red and allow the director to take another chance at it The middle section is what we call our uh alert, um Lean daily management board and so we have key performance indicators on there and so These the senior executive team rounds with the staff Every day and every morning um The the a member of a staff walks us through their goals And so you see there are three of them up there. Everyone has a safety goal That's the s There can be a quality goal an inventory goal or delivery goal that they choose These are metrics that There's not an obvious fix for we're not sure exactly what the problem is, but there's a problem here and the the staff themselves choose it It's not a top-down driven Maybe that they don't they don't get lunch and let's track some data It may be that there's a safety issue Or they don't they don't have what they need when they need it So it's an inventory issue And so the idea is they put a very clear goal up there and then it's marked red or yellow for the previous 24 hours We come by if it's marked red on that top one, then the second sheet is just merely how many incidents Incidences um, did that happen of that they did not meet their goal and then the most important one is that third Sheet that I know you can't read but it has all of the reasons It's a Pareto chart, you know what why didn't we meet our goal that day? And eventually you collect data over time it results in a bar chart and and uh, whichever the longest one is Should get our attention to to dig deeper in that last Sheet on there you see there's the five whys so that's one maybe our there's our opportunity and it may have been what we predicted and sometimes it's actually The data is showing us something new that we didn't expect to be the problem And so then we want to dig deep into the five whys and there is a principle of high reliability of Reluctance to simplify so we don't just take the first obvious reason We continue to ask why until we think we get to the root cause So this is data driven decision making. Um And then the final um column you see that says quality that's blank on these boards These are non clinical boards We gave you an example of but all of our clinical units in this section have a safety checklist on it And so the safety checklist is something that someone is Has ownership of every day walking through the first thing in the morning Walking through the environment as if you were a joint commission surveyor looking for any safety issues And that uh that may have and then that has a bar chart too So the most frequent safety issue becomes apparent with a quick glance at the board And uh the the top of the board you see are keys to to success that we've chosen at our hospital is safety quality empathy and respect Not one without the other but in that order. So if anyone is Uncertain about what to do. They should have their guiding Prism that they they make their decision through as safety first and if they're not sure They don't proceed in the face of uncertainty and they need to get a cross check or um, you know validate Their decision making I think that's yeah, so the next one is a another tool that we use As I said in the morning, we we we have every unit has a A brief of their own in that brief they go over safety concerns for the day and situational awareness, but also Any high reliability any staffing issues and then a representative from that group is present at this 915 Organizational safety brief that we have every day seven days a week It's run by the senior leadership member a team That's on call and we start at the very top with any high reliability recognition And they're often examples of people using the tools called arc and ipass and s bar We we allow You know encourage any kind of teamwork recognition in this section And we frequently get three or four or five throughout the organization And then going down we talk about what are significant safety issues facing the organization and so that everyone has situational awareness another principle of high reliability is sensitivity to operations And here there's a large group is probably 20 to 30 people on this every day So they have a situational awareness It's also preoccupation with failure what might happen. And so that everyone knows and um, and then what you can't see Because it's a little cut off on that screenshot is is you start going down through every department Reports out so the emergency department all the clinical departments go first, but In addition, you see education and it on there and evs and facilities and safety and security and quality all report out on Any kind of issues that they have and then if there's any needs we put them in these follow-up items if something is not Immediately fixable and so this is another principle of higher reliability is commitment to resilience So we want to close the loop and make sure that things that are brought up are Or errors that that may have happened that we look into it figure out why and fix it so it doesn't happen again There's a there's an estimate that once High reliability is embedded in an organization that over the course of two years There's significant safety events Can drop by 80 and we see you know from the airline industry in the nuclear power industry that adoption of these standardized tools allows for persistent success in operation without significant errors You know, adjunct and mentioned our goals to become a five-star hospital this is predominantly a Main tool that we think will get us there And the we're not where we want to be our grades right now reflect the Culture and operations that were happening about two years ago one and a half to two years ago in 2019 and 20 and you can see from this Data set that a hospital acquired infections. We had too many of them from different types of infection are not as important, but You can see when our high reliability journey started you can see that we're trending in the right direction The next slide will show hospital acquired conditions and it's just an example one example Which is falls the top are the total number of falls and then you have falls with injury is the bottom line again trending in the right direction and then The last slide that I have here. I believe is the hand hand hygiene. We had an organizational safety I'm sorry organizational I'm Goal to improve improve our hand hygiene and this shows what can happen when you develop a shared vision you you have transparency of Data frequently you employ The principles of coaching being willing to be coached yourselves and teamwork With signage lots of different strategies, but we've moved it in the course of one year 20 percent It's not where we want it to be yet, but this is an example of working together with a shared vision and a common goal to try to Improve the safety for our patients And I believe the next slide. I'm going to turn it over to Stephanie bro or chief financial officer. Thank you Now I have to try to unmute and talk in advanced slides at the same time So we'll see how it goes, but I I'm going to try Um, so this first slide here really just to kick us off I'm going to walk us through our net patient revenue And just an overall summary of our budget request So whenever we you know kind of embark on our budget process for the year We have to look at our current year budget As a starting point. So in this case our approved current fiscal year net patient revenue budget was 115.9 million. That's that top number And then we have to ask ourselves the question about physician transfers So did we have any physician transfers into the hospital or out of the hospital that would Require us to really adjust the starting point and in our case we did And we're going to talk about these physician transfers In some bigger detail in the next few slides But in our case we had several physician transfers out of the hospital So we reduced our starting point by 4.4 million So our adjusted starting point this year was A net patient revenue of 111.5 million And then we go always to the green mountain care board budget guidance That you all provide to us and in this case The maximum allowable growth was 8.6 percent So 8.6 percent is that 9.6 million dollar number And we know that the fiscal year 23 net patient revenue cap Is 121.1 million And so that is the cap and you will see that the budget that we have submitted today is just under that cap Uh overall NMC is asking for a 9.4 percent rate increase And we plan to apply that rate increase as 11.01 percent to our hospital based services And a zero percent uh rate increase or Charge increase to our outpatient professional fees. So this means And we've done this for several years. We feel it's really important For our patients to be able to go see a specialist or you know a primary care physician and have an office visit And to have the prices of those services Remain at you know what we feel is a fair and affordable level So we do that on purpose intentionally and strategically so we plan to do 11 on the hospital side and zero percent on our professional fees So that is just a kind of an overview a high level view of our net patient revenue and our budget request So one of the physician transfers that I want to talk to you about is Regarding pediatrics so Northwestern employed Two pediatric practices so one in St. Albans and one in the town of enosford And on january 1st of this year we transitioned those practices to private practice So those practices still exist in our community They're still serving patients in our community and they now are under the name of monarch maples pediatrics So what this did this transition actually allowed the hospital to improve access For our community for pediatric care because before When we had the practices were employed by us we had providers who were trying to You know run a clinic. They had an outpatient clinic that was extremely busy. These were very productive Providers and so that the same time they were trying to provide coverage for newborns And for other inpatient pediatric care happening here at the hospital So their time was you know constantly trying to be split. They were also on call every day We had to have a provider on call. And so really we had kind of these Overworked quite frankly and and just not a sustainable model for pediatrics So when those practices transitioned to private practice NMC implemented a physician led pediatric nurse practitioner team To really take care of those inpatient pediatric needs So now we have wonderful providers that are providing care Outpatient in their practices and then if we have newborns or we have Inpatient pediatrics come in through the emergency department or they send over a kiddo who needs inpatient services We have a hospital-based Pediatric team that is here and able to care for those patients It's still early that program is still early for us And so I know january seems like a long time ago But we're still you know maturing that program, but the early results We're going to go over those soon and it is showing that we are absolutely meeting a community need there And now i'm going to turn it over to pan persons who's going to talk to us about our other physician transfer around primary care Hi, good afternoon As you know, I pan persons uh been the CEO or at Notch for the last 20 plus years It became an f2hc actually in that in franklin and grandow back in 2002 Early in uh 2001 2021 I should say We did have conversations with the hospital Uh about primary care. That's an area that we Is our focus primary care dental care behavioral health And the discussion came around their two primary care practices and by working with our two boards working together and and the management team And there's lots pieces that have to come together to actually transfer practices Uh staffing and patients Uh, we accomplished it by May 2nd and Uh, it's operating quite well. It it gives us now um eight Eight primary care offices Our commitment is in the rural area. So we have offices in elberg richford Enosburg swanton and And I want to say that we're very dependent On a hospital in our area We need the services. We we use their lab services It's 30 miles to the hospital from the farthest point of some of our patients and in Grateful of the work that they do do Um, we can go to the next slide Stephanie Putting this together and working two organizations working together. It's important that as management changes and board changes that we develop a A strong Agreement that is continued continues over the years And that was a conversation that the notch and nmc board Had and committed to so We've created this joint steering committee will be meeting quarterly And and and admin can talk in between those quarterly meetings about other opportunities But looking at our community as a team, you know, what do we need? What do our patients need? What can we do? to help Manage our patients And It's there's there's plenty of work to do and if we can share some of our resources so that We take care of our patients and have a right Formula I think it's important. It takes time I think having the joint steering committee gives us confidence that this isn't just a one time That it is ongoing and we can look at other opportunities Down the road and we expect we will I back to you Stephanie We're going to move into our profit and loss. So here's a look at our p&l And we have both the current year projection And next year's budget on here. So I'm going to start over on the right with the 2022 projection So like jonathan mentioned in the beginning of our presentation, we do expect to have a loss From operations in the current year and right in this shows at the time we put this together that was 1.2 million We actually think we're going to come in You know higher on traveler expense. So I anticipate that our overall Net loss for the current year will be around two million dollars or just over two million dollars Um, those numbers are getting a little easier to predict now, but we only have a couple months to go And then moving over to our 2023 budget column um, you can see that the net income from operations is 1.2 million so for northwestern that is a 1% operating margin and again our goal in the long term Is to have a 3% operating margin? This is a look at our balance sheet again the current year projection and next year's budget We're going to talk in a minute when we look at the cash flow statement about This decrease you're seeing for current assets That would be a decrease in cash But there are no significant changes In any of these categories from year to year and I think it's always just helpful to point out that you know NMC does not have any plans to issue any new debt or take down, you know any new debt agreements. So And here is that cash flow statement that I was talking about You will see that beginning cash of 77 million and ending cash of 75 So we are actually projecting it to go down So that is intentional And it's really has to do with the number in the middle there Which says cash used by the purchase of property plant and equipment Of 11.3 million so 5.8 million of that is going to be routine capital replacements And the rest is going to be a capital expenditures related to our approved certificate of need Which is an emergency department renovation So again cash is going down That is not usually what you look for as a CFO in this case that has been Planned and known for for several years So that is what we believe our cash flow statement will look like And I'm going to turn it back over to Jonathan who's going to talk about equity Thank you Stephanie If folks asked about our work in equity and I Appreciate that question because it's something That the organization feels strongly about and it's something that I'm personally passionate about NMC has identified advancing diversity equity and inclusion As a strategic priority It is on our strategic plan. It's part of our engagement pillar But it blurs over into the quality pillar As well because we intend to address it both as an employer but also as a care provider There are concerning issues out there on both fronts that need to be addressed Some of which we have begun to become familiar with and others likely we have not yet uncovered And we can't even see in front of ourselves It is flowing into our annual operating plan and we are in the process right now of Going through the final selection of a DEI diversity equity and inclusion partner to help guide our efforts We're building on the sparks lit by Dr. Avila A national speaker with vermont ties Who lit some embers for us before the pandemic that we have carried forward in very small and fledgling ways I don't want to overstate what we're doing, but let me give you a feel We have become active in our county accountable communities for health work locally And they're carrying a statewide focus on equity We've incorporated diversity into our new patient family advisory group We are we've done some initial work with the abnaki nation We're collaborating with notch on some outreach We reshaped our approach to our community health needs assessment To be more accessible and more driven by the people rather than pure administrative data But again, it's it's fledgling and I'm honestly humbled By the fact that I feel our organization and our industry Is late getting to this work And as I shared that thought with one of our Potential partners he pointed out to me that clearly the best time to plant a shade tree Is 20 years ago and the next best time to plant it is today And so we have humbly embraced that and embarking going forward And so this is a point of emphasis for us I look forward to next year I hope you have continued interest in this aspect Of hospital operation and being able to come back and report more to you On it at that at that point You also asked about wait times and again, this is another compelling topic for the hospital for our community Our wait times are not where we would like them And yet they they do compare favorably with some Benchmarks that are out there and yet they just like our quality scores. They're not Acceptable to us as we move forward You'll see here in this data that for common imaging procedures Access for within one month is at 49 percent Um We would be much more comfortable with that number being at or a little above 80 percent That it would be reasonable um for us to target Getting four out of our five folks who need um a common imaging procedure Um Through that study within a month Similarly for our specialty practices we're at about 40 percent within one month right now And we need to strengthen access to specialty services So that 80 percent of folks who need to see a specialist Can see that specialist within a month And so those are our goals as an organization We've begun to work on this. Um, we've done some really strong work within Diagnostic imaging particularly around mammography To boost the number of available slots to the community and to pull people forward If you go to the nmc website, you'll see that there is a pop-up as soon as you get to the website that announces to our community that additional Availability is possible and it helps pull people forward Getting good traction on that. So this is an area of attention to us But and it ties to the workforce issues It ties to the capacity issues that we talk about as with the burdens on the hospital Um, but it represents both a risk and an opportunity for us Um, this is not a way to run a hospital. It's a way to frustrate a community It's a way to get in the way of good patient care And so it's a risk but as we look at this with good Uh business practices and proper resources We can indeed change this story significantly and that's an opportunity And with that it flows directly into your questions about risks and opportunities And I'll let Stephanie speak to those For me, um, I think this is always the toughest section of the presentation Um, and this year I feel like it was even tougher And I feel like that's just kind of a result of You know, the the environment we're in right now, which is just changing so fast And I know that you've heard that from other, you know, CEOs and cfos And it's no different from us. So when I think so, I just I just jotted a few The point is I probably could have listed dozens. Um For me, you know, first and foremost, I think these first two Are the the greatest risk to our budget. Actually, I lumped the first two together. So any negative financial impacts of kovid and any negative financial impacts of continued capacity issues Are not built into the budget So if we have a kovid surge, um, if we end up with Other capacity issues, maybe it still continues to be subacute patients is our challenge We end up canceling surgeries again. We end up canceling other You know, non-emergent or elective services Those things are not built into this budget and of course if one or both of those things happen Then we will do what we need to do. Um, but just to be clear that they weren't factored in So that's kind of I I lumped those two together and say that's the first one And then the second one we've already talked about it's our reliance on travelers We are gonna come in over 11 million dollars of expense We have budgeted for 8.6 million dollars of expense Which is still a lot it is it is much much higher than anything that I would like for it to be But it's almost a 25 percent reduction. So we have to take a meaningful By out of that apple In fiscal year 23 and move in the right direction from our recruitment and retention standpoint I also have in here as a risk is that inflation is higher than what we budgeted So we budgeted for overall inflation in our expenses of about 8.86 percent And much of that inflation is being felt now. It's in our projections It's in our current year financial statements. But when you look budget to budget It's about an 8.86 percent increase associated with inflation And so if it comes in higher than that then, you know, that would be a risk to this budget There's also some opportunities and for nmc. These are really program and service related opportunities So we have a tele icu program, which is a partnership with dartmouth And that program is not new but it is still becoming fully mature And we also have our inpatient pediatric Program that I spoke to earlier that is still ramping up and becoming mature as well So I think growth in those two programs is an opportunity And then nmc does have a tele stroke partnership also with dartmouth And we will be going live with that program on september 1st So we have built some of these things into our budget But to the extent that we can mature those programs and grow them more than what we have put in the budget That is a potential opportunity I also want to mention here Just to be fully transparent when I talk about What is in and out of the budget? I know you've already heard that the final Medicare rule Did come in more favorable than the proposed medicare rule that we used to build our budget So for nmc the impact of that is a 184 000 So there's there's a 184 000 opportunity that That should be something we can count on I have here just to those first two programs that are already live I just wanted to give you an idea of what we have already seen for growth and what we're planning So these this graph shows you our icu patient days So since going live with our tele icu program with dartmouth You can see where we were at in 2019 and 2020 and where we've been able to grow In 2021 2022 and what we're anticipating for 2023 So that has been a very valuable Growth for our community to be able to to provide more icu services And then this is a very small chunk of data at the time we put this presentation together our pediatric nurse practitioner team was just getting off the ground and so we took At the time we put this together we took the most recent month And said how many inpatient pediatric days did we have and how does that compare that same time frame compared to the prior year? So again still very early. I wouldn't You know say that we've That we've budgeted for that level or that we've kind of matured this program Absolutely not but we're just keeping an eye on it and we're hopeful that that there'll be some growth there Value-based care participation. So our budget does include full participation In the one care program for 2023. So Medicare Medicaid and commercial capital investment Plans going back to this a little bit Our routine capital budget is has been established at 5.8 million for 2023 and I've given you Just a flavor of what that includes by showing you what our top five items are But I can tell you that as our priorities change and as our environment changes We may substitute some of these things out Well, we always have conversations with our board But we will stick to the 5.8 million as an overall budget And then Updating aging infrastructure. This is really a second capital slide So we have an approved certificate of need for renovation of our emergency department Updating that infrastructure really is about safety and it really is about quality It's not just about having the organization look nice What you have here is a picture of our current emergency department So you can see all the curtain bay areas And so this renovation will move us to private rooms The current ed was built over 40 years ago And so we every day we have significant issues with privacy and with infection control And so we very much appreciate the approval and look forward to renovating that space And I'm going to let Jonathan Finish us up All right. Thank you Steph In conclusion, let me say this I am deeply proud of the entire nmc team The care we provide to our community Our focus on continuous improvement And the tireless effort of this team to meet community need In the face of over capacity on a regular basis And we're also grateful for the work and efforts and support of our community partners Um, Franklin county is indeed a village here in northwestern Vermont with grand dial and our surrounding areas And the hospital can't do it alone and we're grateful for our community sport and our partners I will tell you frankly that our community board and our leadership team Fully understand the significance of a 9.4 percent rate increase That's why we held our margin to 1 And it's why we kept our revenue within the cap that the green mountain care board provided We hope that you will find as our community board did that this is a reasonable and responsible request We thank you for your attention And thank you for for making this work and this virtual platform the awkwardness of the The hollywood squares of the brady bunch Rather actually be with you in person So we can actually see each other as we go But do appreciate the efficiency of this and the ability to do it despite whatever covid might be doing So thank you for that and with that we would be happy to answer any questions folks have Great. Thank you, jonathan and team Really clear presentation and some inspiring work here I I just want to say before I turn it over to the board for questions that I really appreciate your quality and reliability journey And your efforts to improve equity and access it seems like You're making very intentional and consequential data driven culture shifts And I would just note that I think change is always hard in normal circumstances But you're trying to make these significant changes during a pandemic with workforce shortages and provider burnout So just want to acknowledge that I can only imagine how difficult it is But how important it is and it's very inspirational. So I appreciate that Um, I am going to kick it over to uh board member robin lunge Thanks jess. Thank you everyone. Uh, it's nice to see you and uh, I was fortunate enough to see you in person Not all that long ago. Um, thanks again for the invite to your community meeting Um, I do want to say before I jump into questions that the quality work is really interesting and exciting and I'm very interested to learn how that journey goes for you. Um, so thanks for sharing that information My first question, I wanted to talk with you a little bit about Your utilization assumptions in the budget. I think your narrative said that you were basing it on Your early Your volume information earlier in fiscal year 22 And certainly you've talked about the capacity issues and in the high volumes that you've been experiencing More recently But then I also note that of the 9.6. Let's call it npr request It looks like about 6.7 million of that is attributable to the rate. So could you Kind of reconcile those two things for me I can start and and devon or others can feel free to jump in if I missed something but Yeah, I mean we always start, you know, february march You know, things really get going in april But we we try to take a rolling 12, you know, stay in march We try to take a rolling 12 months and look at our volumes And say, okay, because if you do a rolling 12, you get some of that seasonality in there, right? And then we do, uh, you know, we meet with all of the clinical or revenue generating department managers and directors and we say You know, what don't we know what's going to change? What's going to make things go up and down? Um, we look at all of our employed Physicians and we actually say how many surgeries are you going to do? How many office days are you going to do? Um, and so, you know, it's it's it's quite a detailed process, but you know, really for us, um We're able to kind of identify those changes in order to come up with all of our changes in utilization And I would say that the notable Things that we're not, you know, a lot of a lot of them end up rolling forward in a way that's pretty similar And I would say that the ones that were not pretty similar were probably our lab um, and so that's one area and Orthopedics was the other area. So we knew Last year when we were putting together the budget for the current year that we had vacancies in orthopedics And so our hope and plan is to be able to fill those vacancies and allow us to bring on some additional orthopedic revenue And you know, I think in terms of other utilization changes from the time we prepared the budget, I would say The emergency department And our inpatient has definitely Um They're running hotter than maybe they were when we went and put the budget together On the flip side, you know, that has caused us to cancel some surgeries And so what I'm what I'm projecting for the current year for surgery revenues is actually lower than what I'm going to be Um projecting for next year. So, um, yeah, not unlike anybody else We've got already some areas where it's not quite what we thought it was back in february or march But we have things going in each direction And I don't know if devin wants to add anything to that but Yeah, I think that's a good description and um, you know, we anticipate this question and the need to break those pieces apart for for this setting and so um everything Stephanie described Results in our initial budget at a zero percent rate increase And then that's what we work with and then any change from, you know, the net patient revenue that's calculated there The change to the final submission is the dollar amount. We know that we're attributing to the rate and it's isolated to the rate Thank you. Um I was wondering if you could if you had we've heard from a couple hospitals, um That they experienced quite a downturn with the omicron surge Um, which sounded primarily for the most part due to staff vacancy, you know, staff being out sick I was wondering if that was something that you all saw up in st. Albans or The two hospitals who've mentioned it happened to be in the southern part of the state So I was just a little curious about whether that's consistent across hospitals Or we're seeing some regionality there or or what your experience was Yes, sir, um, we've not been challenged with, uh, um significant inpatient, uh Hospitalizations for cove it with with omicron. Um, we haven't been more challenged with community acquired staffing challenges. Um So, you know, our peak um Was some time ago. So we've we've been averaging kind of, you know, in the in the below five It in patient census for cove it for many months now But it doesn't sound like that had a sort of dramatic impact on your volumes During that period of time It didn't have a dramatic impact on the volumes, but it does impact our staffing Yeah, we've we've gone from being cove it driven to being cove it complicated That that okay. Well, who's calling out today and how do we patch that as opposed to the terrifying days early in the pandemic of Do we have enough ventilators? So there's still an impact, but it's not the dramatic inpatient Got it. Thank you um So in terms the other question that I wanted to let me just check something here But I think I got you already answered a couple of my other questions that I had marked from the materials In terms of the provider transfers, um So it looks like in this provider transfer schedule for The primary care that's transferred To notch That overall for the hospital That netted out as an operating loss when you had the the the primary care So it's showing your net patient revenue is being about 2.6 million But the expense is associated with that service at being 3.8 resulting in like a 1.3 loss Yeah, um And then with the feeds similarly not quite the same numbers, but um It looks similar what i'm wondering about is in the Schedule A for the feeds. Do you reflect somewhere kind of the offset of the inpatient pediatric that you've retained? Devin can jump in but we did know With pediatrics that it wasn't as a straightforward because we established the inpatient pediatric nurse practitioner team So we tried to estimate The net patient revenue associated With that group coming on board to offset it in that physician transfer schedule Okay, great. I I couldn't couldn't quite tell if it was in there. So I wanted to just ask So I knew what I was looking at um Okay, I think those were my Areas that I just wanted to explore a little bit. Thank you very much Great. Thank you. Uh with that I'll turn it over to board member pellum Well, thank you. Um I'd like to applaud you for submitting a budget that has a Operating expense increase of just 5.5 percent and an npr ffp increase You know of just 4.5 percent Um, I'm and should have done it in such a thoughtful way. Um It's I'm I'm sure there's a lot of heavy lifting there that we'll never know about um, my first question was um in the narrative It was mentioned in and in the in the income statement that you were, uh Putting in a risk reserves of a million one hundred and twenty five thousand dollars for both Medicare and Medicaid in the 23rd 20 23 budget getting tired here. I'm going to be saying 20 23 budget um, and I'm just wondering what Because you didn't do it last year You did it this year and I'm wondering especially relative to Medicaid where there is no reconciliation You know, um required You know, why why you built those reserves into this budget? What kind of risks are you thinking about? I tried to you know, work with the one care team to figure out You know, is the is the risk reserve that we're experiencing now Going to be the same in 2023 or are we looking at a big increase or change in those risk reserves? um And so as you know around timing of when those contracts are due and when we're going through budget preparation and now going through budget presentations We don't we don't have an answer. We're flying blind a little bit Because you know, they don't have it figured out quite yet, but I've got to get a budget submitted And so, you know, we used the best information they could give us but it it did look like there was going to be an additional um risk component to the organization and then and then I always go back and forth of do I Do I include that in the budget submission or do I not right because when when I'm putting together? um A budget packet and it says what is your balance sheet balance is going to be on september 30 of 2023 I I want to give you exactly what it's going to be Right, but I also don't want to fund any changes in risk associated with one care With a rate increase request because then I'm not taking risk um And so, you know, what I can tell you is that if I had not changed those risk reserve levels The balance sheet number I gave you would have been wrong. I think Um, but I can tell you had I not done that the rate increase request would be the same We probably would have we would have showed a little bit of a higher margin still less than three percent You know a little bit of a higher margin, but we would we would still be here Presenting a budget with with the same rate increase request Yeah, that makes sense My next question has to do with I can see here That in the in the pair of mixed tables It looks like for Medicaid your profiling budget over budget a 3.4 percent increase Um, and if you kind of factor out that reserve It would be a 10.7 percent increase And I'm just wondering what it is that makes you think that either of those Medicaid growth numbers Is something that will happen What's the risk that it won't happen? Devin, do you want to take this one? Well, there's a couple parts to that question I think the first is on how did we get those numbers and then second what's the the risk assessment on those And you know the the values that are there are driven by that baseline period Which is the best information that we have, you know Budgeting in a post-covid world is like starting over and learning how to budget And so there's naturally more risk this time around as there was last year To these numbers the best information we have Is The run rate, you know of this, you know Post-covid world for a you know our new normal. I won't say post-covid, but um So so that that's how that's arrived at is because that's what we've been seeing You know some of those utilization changes Stephanie mentioned Service lines do have their own payer mix which gets factored in so as we boost some of those, uh, you know orthopedic and Service lines and lab those may have a a higher mix towards towards the Medicare Medicaid um My next question has to do with the travelers and so you're looking at A budgeting of 8.7 million in 2023 and i'm just wondering How that relates to Budgeting for regular positions underneath is that 8.7 on top or Is this making some assumptions about your permanent employees and regular employees and then that 8.7 um million will cover the full load of the travelers So what we do is we say okay is 8.7 million dollars going to you know buy us 25 travelers But you know, we we decide the number of FTE's Um that we think are going to be staffed by travelers And then we determine what we think the traveler rate is going to be which we have seen come down a bit Which is the good news and so we budgeted at that lower level Because we have seen it come down from its peak And then you know once we have our traveler budget established We take that number of traveler FTE's and figure out what if they were regular employees What the salary and benefit components would be that we would have paid and we back that amount out of those lines So that we're not like double dipping or double budgeting If we end up coming in way under budget on our travelers I mean nothing would make me happier than to come in over budget on my salaries and wages because of that But we would have an offsetting variance because we try We try to you know, like I said take take one out of the other even though one is much more expensive So this is uh So this is a question that It's probably I could probably answer it, but you know given the pressure of travelers And the the pressure on the budget from them There is money kind of You're directed toward them and at some point we hope and as you just expressed that that goes away And so if it does go away Um would you um Would you kind of think that repayers should benefit a little bit from that and that the hospital should be able to kind of then reinvest Some of that traveler money Into things the hospital needs. I'm just I'm trying to think two or three years down the line I know it's a fanciful thought, but um, it's a lot of money Yeah, so I think it depends right like how much did we beat did we beat that number by right? If I beat that number by a million or you know and and what happens with all of the other expense lines of the budget So did inflation not come in higher than what we thought it was going to be and we really beat our traveler budget Um, or did we really beat it? But you know COVID surge happened again hospital capacity issues continued had to cancel surgeries Inflation came in higher. So I think it depends what else is going on um and the magnitude of the dollar amount, but I can tell you that um You know the only way because you guys have allowed an 8.6 percent net patient revenue growth for two years And we're using it all in year one We all know in this organization, especially at our senior senior leadership team and our board level We all know that the path to a viable budget in 2024 Is to get that traveler number from 8.7 million Down to four or five million because that's where our operating margin is going to come from the next year um, so we have a very um intentional specific schedule look like okay Here's how we have to ramp these down and it goes by month Um, and you know here are the milestones that we need to hit in order to stay on track with this um And so it's yeah, it's a very fair question Two more questions. Um one is that you I think I could be wrong But in terms of these hearings, you're the first hospital to reference the 8.6 percent, uh guideline um and uh And I applaud you for that. Um, and I understand your rationale. I mean, it's kind of a fixed perspective You know cap, but other hospitals You aren't referencing it and so uh, what happens if If we approve your budget as requested um, and we approve other budgets that um, uh Exceed the guidelines What would north westerns? I mean, what what do you think your your board would think about that? Because it might be attention that we're going to have to face I'll start and then we have a board member here who can jump in Um, but I think you know, I I really truly believe that every hospital asks for what they need Um, and we always want to hit the guidance. We always want to follow the rules Um, and so for us, you know going over 8.6 percent So that we could have more than a 1 percent margin And would jump our rate increase request into double digits We just couldn't do it, right? That's just not what we wanted to do For our monitors and our patients in our community for ourselves as an organization We wanted to feel like we were gonna own some of The you know the state of You know the health care in vermont that we all find ourselves in right now Um, and so it really you know, it was a budget based on need I think everybody says and so you guys do not have a easy task Um of trying to determine That everybody's budget is based on need, but I think we would still feel Um satisfied happy and content that we put forth a budget that really was what we needed And I can let Jake chime in Thank you, Stephanie. This is uh, Jake Colchater, the board board president. So, you know We wouldn't go to Stephanie and say hey, you didn't ask for for you know for enough. That's not really the way we We think um, I I I believe we ask for what we need and I believe that if you did approve for others um, what went over that eight six that we would probably Try to look for the reasons why and where they're Extenduating circumstances That for certain hospitals that you decided that it was okay where it made sense Um, because I'm sure that it wouldn't just be done without a very specific reason that we would understand um, and I think most would look at it that way And not look to come back next year and get our share of what we didn't ask for I think we're always going to ask for what we think we need Even if it's if it if it's over your guidance I can tell you we would make a very compelling reason as to why and it'd be very thoughtful and purposeful So I hope that answers your question Well, no, I think thank you for for that frankness Um, and I will tell you mr. Pelham. It's not the first time that question has been asked Our own hospital staff in our own hallways have asked us as they've seen different things come out in the media Of why we did what we did And they've understood the answer is Stephanie and jake have presented it and so I think these two have represented us really well But it's not the first time we've had to answer that question. So I appreciate you asking it It's a tough place to be I I can appreciate it, but thank you for being there And my last question is just one that Kind of gnaws at me and I don't know if there's a basis for or not But one of the reports that was referenced in the supplemental That was sent out was the reimbursement variation report that we did last Last spring and in there there were I went and looked at it up the other day and there were 32 Procedures that were covered in it 19 of which were included northwestern and of the 19 UVMMC's median reimbursements were higher than northwesterns across all 19 couple of examples One would be vaginal delivery at northwestern the median was 5,957 dollars in a U that the The medical center it was 14,800 dollars for a colonoscopy with a legion Removal it was 2,144 at northwestern and 5,957 at the medical center And just one more here an MRI spying An MRI of the spine northwestern was 1877 dollars and the medical center was 3,999 dollars So my question is is that should this variation Be a concern of the boards this board When considering budgets or do you think the current marketplace is accurately reflecting reasonable outcomes? And you know again anyone else can chime in from my team I think when we look at the supplemental data That was that was part of it. And I think we put this in our narrative. I do think that our Payments or our net revenue whatever the the proper term is is understated You know, I think we you know what you're seeing for numbers I think are is a little bit understated and that's just me being completely honest and transparent We would have to go through it, you know kind of item by item To be very specifically view, but I do think whether it's the fact that we're a sole community hospital And so maybe that sole community hospital layer is being missed because there's an enhanced payment for that or whatever it is The variances are probably not quite as big as what as what you're seeing, but But I appreciate that I mean I think in general when it comes to overall Both what we what we charge and what we get reimbursed There are differences that make sense, right? It makes sense for sole community hospitals to have something different than a tertiary You know facility to have something different than a critical access hospital And so I understand that there are going to be differences I think the real question that I can't answer for you is how you know, how big are those differences? When did the differences become too big? you know And I would add just one thought Is that as you see graphs such as Intensive care unit patients being able to be cared for in Northwestern instead of having to go to the tertiary care center where there's already access issues Or in patient pediatrics being able to be cared for in the local community rather than parents have to travel to burlington Know that there's good reasons for that and there's some impact on the overall cost of the entire vermont health care system and that there are some efficiencies to having Care provided at the local level in community hospitals And there's a real role for us here and we desperately need a tertiary care center that has capacity, etc We have one great relationships with uvm But I hope when you look at those graphs and say okay nmc is is working hard to meet their community need and keep care local That you reflect on some of this and even if the numbers are not perfect as Stephanie says There's a there's some insight there And one final comment I remember when I was First appointed to the board and took a tour and was at your hospital and I was in the emergency room and there behind a curtain was a Patient and sitting there in a chair was an officer with a gun You know and so when the um c o n came for the emergency room That was a just a a thought in my mind You know that just said this is the right thing to do. Um, it was just shocking to me. I just never expected You know to see that kind of uh contrast of A patient I think maybe with some psychiatric issues sitting there with an officer, you know with a loaded gun So, uh, I really hope that emergency room kind of ends up being what you want it to be Uh, and with that I'll pass the ball back to jess Great. Thank you. Tom, and I will pass the ball over to our other tom tom walsh Thank you jess and um great questions tom Right sir, I I just I it's this is a I'm very glad that we're ending the day with you folks I want to thank you for submitting such a A clear Budget and doing such a a clear job explaining your assumptions around it It's obvious that one of the Big things that you'll be working on in the next year to coming years is trying to reduce the reliance on travelers and um recruit and retain And I think that your choice to start on this The the term of phrase is a high reliability journey I've worked in that for the four years prior to Being appointed to the board worked with uh, dr. Chason at the joint commission for a number of years And was part of the effort To bring high reliability principles and practices to all of the 173 va medical centers Across the country. So I'm deeply familiar with what you're trying to start And and the path that you're on And anybody who's done that will say that that work all begins with looking at your culture And addressing that culture is uh, one of the key aspects to recruiting and retaining Um, most people don't know however that there's really solid evidence That efforts to improve the safety and reliability of an organization in health care Is also highly correlated with improving outcomes that matter to patients So it's not just an exercise to um Get to zero harm which is with zero preventable harm, which is very noble mission But in addition every day patients where there's no error in their care also benefit Less well known still Organizations that are successfully moving through the phases of maturity for high reliability There's solid evidence that their financial performance improves so um your Everything that I've read over 30 years of health care delivery and health policy You're on the right path And your budget was there's there are struggles, right? But the way that you presented it Clear straightforward able to easily answer my colleagues questions about your assumptions And it's just it's Good for you You're on the right path and um I I I hope that everybody around the state gets to see what you're doing and how it goes Um, and so I'll turn it back to you. Yes Great. Thank you. Tom So I just have a couple of wrap-up questions. I think the first you probably have Prepared for this because I've asked it of every hospital But I'm trying to understand the relationship between the the 9.4 percent change in charge And what the effective rate that a commercial rate payer in your community will really feel in their wallets And so I know there's it's not a direct correlation, you know, or one for one mapping there. So Um, I'm wondering if if and I know Stephanie you you may have this answer because I know you're always prepared And you hear what I ask other hospitals But if you haven't that's okay if you could share that with sarah linberg afterwards just so us to understand What that effective commercial rate experience will be Yeah, no, we're happy to share it. I I have heard you ask it and so You know, I've I've already kind of huddled with devin a little bit and said like the answer is pretty close and pretty much 9.4, right? Um, and so yeah for our organization, it's not going to be a A big difference. It's going to be close, but we're happy to you know provide that information to sarah and yeah Okay, no, that's helpful because as you notice it is different for some organizations There's a significant deviation between that and so we're trying to understand that better Thank you for that. I appreciate it My second uh area I just want to actually say I appreciated the comments that you've made on capacity and measuring occupancy rate using staff beds and not licensed beds And in fact, uh, it was your reaction to that report that led us to bring this data in To the guidance this year and asked specifically for the differences between staff beds licensed beds and the average daily census and so Um, I really appreciated that and the narrative and it's really helpful. So we're gonna, you know, we'll probably be Uh, hopefully getting that from all the hospitals. We didn't get it from all the hospitals and their submissions But we're trying to circle back to get that information. So we really can understand The capacity issues in the system And this is just a parking lot, uh Idea, but I I do appreciate the impact and the growing costs associated with the throughput issues in our communities and You know log jams in the system as it relates to placing mental health patients in appropriate settings placing patients in post-acute settings and I suspect for northwestern that the um The the cost has been tremendous and I you know, again, not for this process, but I'm hoping we can have Conversations down the line where maybe, you know, if if you guys could take a leadership Maybe with southwestern who also has expressed this serious issue here It would be really helpful for us to start to roll up what those annual costs are And I mean like direct costs of patient care for those patients But also inclusive of lost revenue, right? What if you have been able to place that surgery that you've had to cancel in that bed? What was, you know, the the opportunity cost or the indirect cost that's lost revenue? I think until we start to quantify those costs, we're never really going to start To to bend the needle, you know move the needle on this and really make a difference And I think it would be really helpful if we could and also If there's a way once you quantify the annual cost you can back into what is the what is the cost of the commercial rate payer, right? What is that increase in change in charge or effective commercial rate that we're asking? To cover these costs that if we had better throughput through the system We'd be able to eliminate so I just it's a it's a request to you know, maybe and maybe if Mike Del Treco is listening To pull together hospitals to do this and and maybe those some of those dollar values and impact on on change in charge and commercial rates will Help us gain some momentum to try and find some solutions and to be fair I know people are working on you know these issues, but sometimes when you put a dollar value on things You know in a light a little fire. So I'll just say that Jessica you didn't ask a question, but I'll give you an answer to it Because when I go back from this hearing and and report your observation and concern about the impact of throughput on the system Our emergency department medical director and the ed nurses will be thrilled Our care managers will be so grateful that you folks are tuned into that our progressive care unit nurses Who just really want these patients to get to the right places in nursing homes or in in mental health hospitals, etc They will be grateful that that this resonated with you and that there's a system issue and we can all work together on it So so I will relay that and people here will be pleased Yeah, and offline if you want to talk further about this I'm happy to talk about that and maybe think about how we can gather this data I think it will feed into our long-term sustainability planning efforts that we're trying to do through act 167 I mean, I think that's a place and a placeholder for that for that kind of work so again Stephanie not for anything with this process but A plea to like let's see if we can get some of that data together so we can really understand this. I think tremendous issue I You know a really thin margin For this year, you know for fiscal year 23 I appreciate the fiscal conservativeness of that and trying to not have a huge impact on your community in terms of affordability There's so much uncertainty. So a little, you know, obviously worry some worry some about all these budgets Um with that uncertainty in in there in the air um, I wondered and usually Board member lunge asks this question So I it's going to be me today since I think it she didn't today But I noticed that there was no targeted cost savings initiatives in place and given that thin margin I just wanted to be could speak to that decision We have put in, you know 500,000 or 750,000 worth of unidentified cost savings And have done a pretty good job actually at achieving that number So this year when we put the budget together we asked ourselves like would we be successful if we did that? And we felt like it would not be responsible this year to do that But we have been really good about doing that in the past and so I think what I can say is You know, again, I've heard other presentations. And so when I listened to southwestern, for example, I was like Ditto, right? I want to just say ditto about steve when it comes to, you know, every single time we were new A contract or enter into a contract. We're asking ourselves. Do we really need the service agreement? Or are we gonna, you know, risk it and say we'll just pay time in materials Are we going to accept a contract that has anything bigger than a cpi increase? No, we're not Are we going to go back to the vendor every time and ask for them to do better by three or five percent? Absolutely we are and so, you know, that work continues the senior leadership team already Has identified a couple of investments we want to make that we didn't budget for And so we've challenged ourselves to be extremely disciplined around Finding the thing that can come off in order to make an investment in this new thing And so, you know, it's it's definitely work. We're still doing every single day I just didn't feel like, you know, it would have been responsible for us to put in something that was truly unidentified Got it. Well, I appreciate that I just my last kind of question is around the wait times and I appreciated, you know, your submission around the wait times This is this is our first go at really trying to collect in a more meaningful way some of the referral Lag and visit lag data Given some of the wait time issues in the state. We've collected it on and off in the past But we're really trying to, you know, get a better understanding of what is a good metric here And I really appreciated your efforts to submit that data I noticed that you didn't have you aren't collecting Data on when the dates of referrals are made so you weren't able to, you know, calculate the referral lags and You know, I can appreciate that. You know, we started this in March and you can't just change your systems overnight and all of that Referral lags in that wait times report were a real source of frustration for primary care providers that we spoke to That they would make a referral and they wouldn't and I'm not saying this is specific to northwestern This is general, you know, kind of feedback that we had from primary care providers across the state So referral lags were a real source of frustration for primary care providers Not knowing when that actual appointment would be made So I guess I would just ask if it's possible to consider your systems and think about ways that you might be able to track that Date of referral and begin thinking about how you can track referrals Referral lags, I do think they're important access metrics. If you don't measure them You don't know if you've got a problem. You can't fix a problem. You don't measure, right? So That point and then, you know, as we think about one of the reasons we were trying to get information about Access and wait times was to really understand by specialty, where are some of these log jams in the system? And so you submitted them, you know, aggregated by all specialty practices It would be really helpful to see them disaggregated You know by by practice area So if that's readily available, it would be helpful to see if it's not just pin, you know, pin parking lot for next year These this is the type of data that we're trying to Calculate or you know measure understand so we can understand the whole system. So Thank you for that If there's any Information that is relevant Since your budget submission that you didn't talk about today related to any changes in federal or state payments Relief funds donations grants, you know, unexpected increases in Medicaid or Medicare It would be really helpful if you could follow up with information to Sarah Lindberg. So that's kind of my standard kind of parting question or request, I guess I would say That's fantastic. Thank you I at this point any board members have any follow-up questions that they would just like to ask Shake it ahead. Okay Um, then I will ask Sarah Lindberg if you have any staff questions team questions for Northwest Uh, hello, Sarah Lindberg. Uh, it's head of the GMCB finance team. No questions. Uh, thanks for a very clear and timely submission All right, well then that's easy. Well, I see Sam online. So Sam it is I am the ball is coming your way The health care advocate Good afternoon. Good to see you everyone folks from Northwestern, Sampaish Health policy analysts with us the health care advocate and I'll try to keep my questions brief because I know it's a long day for everyone Um, just want to start out Northwest by recognizing how you have continued to approach your DEI and health equity work With a lot of humility and I think that really shines through in your presentation and particularly in how you conducted your community health needs assessment Particularly the formal interviews and focus groups you did with the indigenous community in your area I think that that's really critical and I think a lot of hospitals can look to you as a leader in this area So just wanted to take a second to recognize you for that Um, and our questions actually stem all of them stem from findings in the community health needs assessment And the first one is one of the major findings that you reported is that community members lack access to reliable Transportation as well as high quality nutritious food I'm just wondering if you're what you're planning to do to address that as a challenge Yeah, thank you. I Appreciate your attention to it and I will pass along Your words to the group that put that community health needs assessment together with denise smith Here at nmc being point but it being a broad community effort. Um, so thank you for that Um nmc's approach To the community health needs assessment is not only different in how we collected the data But how we intend to pursue it The action plan that's coming out that nmc will be part of will be from our account our accountable communities for health And so it will be partners at the table looking at it And so for us the question is in an issue like transportation What is the role of the community hospital in meeting that need? And how can we be better partners with? Uh gmt a the the public um access in there. How do we help foster a community where taxis can be? Um sustainable how can we be a more walkable community? And what's the hospital's role in that and similar for nutrition? Um, We don't aspire to own all of the restaurants and grocery stores in northwestern vermont and control what food is Is out there and and at some point in our past we may have But we've come to the realization that the hospital needs to be part of the answer We can't be the entire answer And so um and as we navigated that it was hard for me and we had I had to Come to the understanding that no that's that's reality and it's pragmatic and NMC desperately needs to be part of the answer We can't be all the answer So we will be at the table with that accountable community for help With a strong and some in some instances it may be a financial investment is needed from the hospital Or it may be advocacy in the legislature about the need for high speed internet So that we can do telemedicine in towns like sheldon um that don't have Great service. Um, so we're searching for our role in that And again a little bit more back into the humility piece of recognizing We got to be part of the answer. We can't be the full answer So I don't have details for you yet because it's work in progress, but I love the fact that you're aware of it Sure. Thank you for that. That's helpful and this this might speak to the finding your role question too But one other finding that I wanted to highlight and ask you for feedback on was 30 of respondents talk about elder care and dental services being inaccessible due to cost and again like Some of these things overlap with partnerships. I imagine they kind of will community work you're doing Wonder if you can speak to the affordability challenge yeah, I I would say the affordability challenge feels like it goes All the way across health care and so I it Yes, our our community health needs assessment did look at elder services In potential and dental services We've been fortunate in recent years that notch has been able to add dental services to the fqhc in rural areas and That was was something that that we had to wrestle with as a community and It has worked out. Well, and I think it served our community. Well, there may be opportunities in the future for notch to to do more in dental to help with that And elder services are a concern for every partner At the table around how do you do that? Especially for folks on fixed income So I don't have great answers for you, but I can tell you as we move through our prioritization process now we're out at a lot of public gatherings and Help getting our community to it's almost a dot-mocracy of the community weighing in on all these different priorities Where do you see the emphasis? One of the real areas of emphasis that folks have is on that that access and affordability piece So I do know our community will be will be focused on that Great. Thank you so much. Those are all my questions back to you chair homes Great. Thank you, sam At this point, I would happily open it up for any public comment If folks have a comment they would like to make they can use the the raise your hand function on teams and I can see Those folks or alternatively up. I see one. Okay. Kathy Fulton. Hello, Kathy Hi, Jessica and board and um, thank you for the opportunity. I just want to recognize dr. Minnidale's description of their High reliability journey And just say that we at vpqhc on a recent patient safety visit to northwestern Have the opportunity to see those amazing practices literally in action and Tom walsh to your comments. We are we have already invited northwestern medical center to present Information on their processes for their high reliability journey to the quarterly quality directors network so we'll have an opportunity for all the Quality directors across the state to benefit from this wonderful program great culture and Wonderful learning experience. So thank you very much. And I just want to Recognize northwestern for all their hard work and great efforts Thank you. Kathy. Yes, it's very impressive And most appreciated. I'm glad there'll be some sharing of those learnings Anybody else from the public Wish to make a comment Okay, well seeing none Thank you to everybody. Thank you to northwestern. This is a great presentation. It's been a long day for everybody, but uh, we really appreciated the clarity and the inspiration in your in your presentation We will be back here the board will be back here online at 8 30 on friday to hear the three hospitals associated with the uvm health network So that is stay tuned more to come With that in mind again, thank you to northwestern really really appreciate your time today Is there a motion to adjourn? Okay, robin moved and I will take tom pelham as a second on that motion everybody in favor Hi. Hi. All right. Any opposed? No, all right. We are officially adjourned until friday when we come back at 8 30. Thank you again, everybody Thank you so much folks. I appreciate it. Bye. Thank you