001All right. It is 6.15. I'm going to call the meeting to order. We just completed a closed session. I don't know, but you should probably turn yours on. This is our first session here in City Council Chambers for years, so we're probably going to have some glitches to work through. And to that end, I would just like to say as a board chair comment, that if those of you who are watching this virtually are experiencing any difficulties, hearing, seeing, et cetera, please let us know. Give us that feedback. Monique, the board clerk wants your feedback in case so we can improve the experience and be able to include everybody who wants to be involved. So thanks for that. Anyhow, we did just have a closed session and it was a report involving trade secrets, a
002trade secret. And then there was a discussion about a proposed service and business strategy. The board did approve negotiating for a service contract. At this point, I want to note, we'd just like to say if there are any public comments, this would be the time to do this, commenting on anything that is not currently on the agenda. Okay, then we'll move on from that. I'm going to go right to the consent calendar. Everybody had a chance to look through it. Do I have a motion to approve it? A motion to approve the consent calendar. A motion to approve the consent calendar. I second that. Thank you. Those in favor? I second. Madam Chair, I cannot tell who is making the motion. Oh, okay. Repeat the names for me. Sure. Denise made the motion. Bill seconded.
003Well, that's nice. We can see all of you who are, well, some of you who are attending. Thank you, Vivian. I would just like to make a comment about those, though. I talked with Kylie for a little bit about the last item there, the policies and procedures. And I would just like to comment that there were a large number of policies and procedures to go through. And I was just struck by the fact that a very small percentage did not make any changes, which indicates to me that they were really looking at this very thoroughly and just updating for whatever reason. And that just, it just seemed very thorough to me. And I thought that was a very positive thing. And I wanted to make that comment. Okay. So chief of staff report is next
004on our agenda. Dr. Solomon here. Yep. Hi, I'm here. There you go. Everybody. I can't really tell who I'm talking to since I can see all the Zoom faces, but I guess there's a fair number of people that are there with you. That's not the case. No. No. Okay. We are feeling very lonely here. Okay. Well, I can just take you through a quick report here. I know we got a little bit of a late start. Do I have control? No, I don't have control. Go ahead. I didn't expect it to be in a slide format, but I guess we can click through this. The next slide just shows these are the current medical staff. So I've got 143 medical staff, 50 of them are active. You can see a list of here of the
005new medical staff. Some of them from different reasons. A lot of the emergency department is a lot of new staff. but they may be kind of rotating in and out. So not really sure there. The anesthesiologists are part of my group. Those are all just people that are growing as our group continues to grow and turn over and having new staff here. So that's all pretty stable. On the next several slides here, we go through some of the HCAHPS. which were given to me by Jessica, who is here on the call, but I feel like I'm presenting her information. These are presented this time as top box scores. You know, when you get these ratings where they just want to know how many people said it's a 10 out of 10. Sort of like when
006you go to your computer, I mean, a car salesman, they just want to know we want to get fives on everything. That's what they tell you when you leave the car shop. I don't think we tell people that, but you can see here what our different ones have been. So let's see. I'm kind of moving quick. Can I go back to the first one there? Okay, here we go. So this is just your basic rate, rate my hospital, which I think is in some ways kind of the most important. How many people would leave and say, I would like to rate this hospital. If you look at the graph, you can see we've been growing very well over the last, you know, since I guess was a low point in Q3 of 2021 when we're
007in the throes of COVID. So you can understand that everything is to be taken with a big grain of salt these days as we're kind of adjusting to pandemic and post-pandemic times. This is kind of holding the stable. The last quarter we were 77%, which was the 81st percentile of saying that they would recommend this hospital. On the next slide, you can see, did we just jump to, yeah, here we go, to recommending the hospital. This is like the same slide, is it not? I feel like this is somehow is a duplicate slide. Okay, let's move forward. Sorry about that. Next one. Okay, so this just gives you another little idea of what's going on with where people write our top box trends. Again, we had, you know, we're coming out of COVID. We went
008to a new EHR in December. So you can expect that things were much slower and different than they were at the time. And it's sort of reflected by a downward trend in December. I'm not sure what to make of it other than we're transitioning to a new system. So it's hard to really know. I would expect things to bounce back quite well. I did note that the discharge information still stays pretty high and maybe that is because it's from the computer system and expecting that information will be one of the great advantages of this new system. So we'll see what that looks like in the future. On the next one, again, just a few more of these edge caps. Here's ambulatory surgery. This is the area that I'm most directly in control of. You can
009see it does not look great for recommending the facility with a decline in Q4 and Q3 as we get to a new computer system. I think all these numbers are always going to look a little bit low to tell you honestly because We are an ambulatory surgery center that's connected to a hospital and compared to ambulatory surgery centers that are not connected to hospital. It's just a lot easier, I think, for patients to come in and have a good time, make it like the only thing they're involved in. So we're doing well, but you can see even there, like some of those numbers that are even, you know, let's look at 78% say that's a top box score. That's three out of four people say, I give this a 10 out of 10 that I
010would recommend this place. Sounds pretty good. You look at the national percentile rank, it's 16%. So amazing. It's very low. I guess people generally really like the facilities even more. So we'll watch that. I expect it to come up just like everything else, but we'll see how it goes. Okay, moving through. Again, there we go. Just a couple of, I just wanted to throw this one because it's just like facility, the personal treatment. Again, you can see the, if you look at the graph, the numbers are kind of going down again in December, like everyone will. If you look at the numbers of top box score, were you treated well? 96% of people say, I give you a 10 out of 10 on the way I was treated. That I think would be extremely good.
011That is the 35th percentile rank. nationally. So amazing. We were 99.18% in Q2 of 2022, you can see, which is a much higher rank. And I think that's where we can hope and strive and expect to be. But those are pretty small differences that seem to make a large difference in that percentile rank for whatever that is worth. Okay, moving on. Again, another one on discharge. You can see here, at least the discharge was going well in December. Not everything took a downward turn. Here's something that was rated a little bit better. But you can, again, look at those numbers of percentile ranks. Very, very low. So even though we've got people, four out of five people saying this was fantastic, we really should be expecting 9.8 out of 10 people saying this is fantastic.
012So there's definitely room to grow there, even though it still seems pretty good. Okay. Moving on. Okay. A couple other things. Now the Q reviews, the score by department. Again, good as usual. Emergency department, 4.6 on an overall score, 4.7 for the inpatient units and 4.9 for surgical services. All good scores. Moving on to the next one. And there you can see the ones, these are the questions that they use. You know, how would you rate them? How much time did your doctor spend with you? The technologist, how would your test explain to you? All of these out of five, everything in the 4.5 to five. So again, all pretty good numbers. But we expect these numbers to be great. I mean, we expect everybody, you know, that's what we're striving for. We want people
013to go away and everybody to feel like, yes, everything was explained extremely well. So they're good numbers. That's what we should expect. Okay. I think I just, after that, just have some summary comments of my own, just for you guys, just what we've seen the last sort of three months, I would say. The big thing that we had was our transition into the electronic health record. And I know that talking about it, there are a lot of people expecting it to be pretty rough transition, but it went. Quite well. I mean, it was, you know, there were some bumps in the road, but as I said there, there's less bumps than many expected. And I think that now as people become comfortable with the system, we can expect it just to improve patient experience as
014well as our patient care. I think dramatically, there should be no reason for people not to have excellent communication. And we're going to start to. be able to see a lot more of the data as well that can help improve our own system. So we just got the system in December. It's now three months later. And I think I would give it a year until we really kind of can see what we can do with it. But I'd say we're off to a good start. As far as the MEC is concerned, it's been busy. We just did a big search for a new emergency department group, which is be a major and important event for the hospital. I think it's going to work out well. There were some really good candidates and I think we
015have an opportunity with our emergency department to really. step this hospital up. I think there's a lot of room for growth there with a new electronic system, a new group in the emergency room. I think it's going to be the kind of thing that our our area, our people, our constituents are really going to like. So I'm feeling pretty good about it. And the whole process went very well. I think in the last 10 or 12 years that I've been here working on these sort of things, I thought that this probably was run as well as anything that we've done. So I think that our team just continues to get stronger and that feels pretty good. So this is going to be in the surgery department where I am also doing well, the adjustment to
016the new monitors, the new machines, Dave Peer led a. Sonoma Foundation that bought new anesthesia machines for the operating room. So we have really top of the line operating facility, operating machines, new monitors, new electronic health record. I think we are just poised to continue to grow and I'm feeling good about it. I think it's all, it all looks good, but it all makes a real difference. More importantly, I think it's going to improve our patient care. As far as the needs of the staff, I think things are going well. Getting a new emergency department physicians and getting a new group there, I think, could help with our future. We're going to turn to the hospitalists next and see how they're doing and see what we can do and just try and continue to improve
017all of our service lines in Sonoma. The more people that we have that are really dedicated to this hospital that can stick with this, can be part of our medical staff, can help this place grow into the future, I think is going to be kind of crucial for us. We're in a sort of a remote place and sometimes you have big groups of people coming in from. distances and it's hard to really get them engaged. And I think what we want to continue to do is I think our engagement level is high right now, or at least it's getting higher. And I think that we want to just continue that. I can see, I feel at least in my team that I work with, a lot of engagement leads to more successes. Feeling pretty good.
018I think that the satisfaction is high in the medical staff. The MECs continue to work well together. Honestly, we just need to keep getting more good people as we sort of move forward. I think this will be my last report as the chief of staff. My term is ending soon. We've got somebody in the pipeline coming up behind me, which will be fine, but we just need to keep getting really good, engaged physicians involved, and that's what we're working on. And that is my report. Any questions or comments? Okay, thank you. Yeah, we got a lot out of all of us here at the table attended the hospital staff evening meeting the other day. And I think we really got a lot out of that too. I speak for all of us. Oh, good. It's
019a nice group of people. I mean, you know, we have a nice hospital with a lot of really nice people trying to do good things. So there's no reason we shouldn't succeed. Wonderful. Anybody else have questions or comments for Dr. Solomon? Yeah, this is Bill Warren. Apart from these survey results and more from the standpoint of the staff, I mean, that is the physicians, the surgeons, if you will. Can you say anything about the utilization of the surgical suites? I mean, does that factor any of this in terms of engagement by surgeons, the availability of space, or in fact, how much of it is used? Well, I can say, Bill, I know that is something you've been aware of for years and you're exactly right. I don't know that it affects any of the stuff
020that I spoke about, only to say that there is definite room for growth. We continue to try to attract more surgeons to come to the area because we have the availability and the space. You know, I'm hopeful that there might be a growth of surgery eventually coming north. I mean, I also worked in Marin County, and there's been a lot of, they also, as you know, have partnered with UCSF, and there's been a lot of UCSF surgeons moving to Marin County and operating there because it's just a lot easier and more pleasant to operate in a small new community hospital than it is at a large academic institution. I think they've grown a lot of space there, but I feel like that space is going to fill as well. And hopefully there's a way to
021keep pushing that surgical work north. But I just don't know how many of those surgeons live north in the area. So I don't know if it affects any of those studies that I stuff that I report on, but there's definitely room for growth. And it's something we're actively trying to do. And we do find that. almost universally the surgeons that come to Sonoma really enjoy being in Sonoma, but we need, what we're lacking is just a steady, more people that just have steady work there, if that makes sense. Informative, thanks. Okay, Kylie, I believe you are next. I am, good evening, everybody. My name is Kylie Cooper, I'm the Director of Quality and Risk. For those of you who do not know me. And I will be giving you the annual quality update for 2022.
022Let's wait for the slides to jump on up. Perfect. If we can put it in slideshow mode, that would be awesome. Can everybody see the slides okay the way they're presented? Sure. Yeah. Yes. Okay. Let's jump to the next slide, please. Next slide. I can share my screen if it's easier. Okay. Give me one moment. Okay. Can everybody see that? Yes. Alrighty. So quality overview for 2022. These are the metrics that are measured and then reported monthly to our board quality committee. We look at mortality rates, any patient safety events, patient falls, readmission, blood culture contamination. We look at stroke core measures, utilization management. So that's looking at discharges and length of stay. Core measures, we look at sepsis core measures, emergency department core measures, colonoscopy, and we look at infection prevention and then inpatient
023and outpatient satisfaction. So our successes in 2022, our mortality rates at the hospital were well below the benchmark for the entire year. We had no falls with injury. Our percentage of readmissions were below the benchmark in 2022, and we also achieved the Silver Plus Award for our stroke care from the American Heart Association. The next slide, you'll see some control graphs. So for the acute care mortality, you'll see a green line. You want the blue dots below that. And we were significantly below that. So that was great. And then there's similar with readmissions. You see the green line. We also want the blue dots below that line. And you can see around May through October, we had a significant decrease in readmissions in the middle part of the year. And then, as I mentioned, we
024did not have any falls with injury. Here was the award that the hospital received from the American Heart Association for our stroke care. So there's five measures that the American Heart Association looks at and you have to achieve 85% in each of those measures. And because we had done that two years in a row, we received the Silver Plus Award. Definitely areas for an opportunity for improvement. There always is. So after 2022, we looked at these and we really have an opportunity to decrease our length of stay this year and to increase our sepsis care. particularly around documentation. So there's continued collaboration between myself and the emergency room department looking at our sepsis core measures. And we've just recently, two months ago, formed a sepsis task force that's involving some hospital staff, medical leadership, and
025then blood contamination by a registered nurse. We have seen decreases over the year, and this is led by the director of the emergency services. He follows up with his staff. And then patient satisfaction, as Dr. Solomon just presented to you, that is a hospital-wide initiative. Here's some of the data, control charts again. For the acute care length of stay, you want to be below that green line. And as you can see, through most of 2022, we were above that line. So we are working diligently to decrease the length of stay for patients. And then our sepsis core measures is the second graph on the right-hand side. You want to be above the green line in this graph, which we were some months, but we did fall below. So we're continuing to work on that. And
026then blood culture contamination, we wanted to be below the green line. And you can see there was quite a few months when we were above that. And Philip in the emergency room is continuing to work with his staff. We had a little bit of a realignment in the quality department. Case management and social work both report to me now. In the absence of the CMO for about eight months, I was reporting to John. Here's our department members in the quality department. I like to say we're small but mighty. There's myself as the director. Cindy Newman is our quality systems and data analyst. And then Stephanie Montesino is our infection preventionist and employee health nurse. So a lot about quality is abstracting data and looking at cases. So in April of last year, we had a
027new company come on board for us called Q-Centrics, and this was formed through a relationship with UCSF. They're a company that provides secure quality data management. And they currently perform all of the data extraction for the quality department, particularly around metrics and core measures and infection control. Any measures or any patients that did not meet the standard, they're individually then given to me and I investigate each of those individually to confirm that what they are abstracting is correct and for follow-up with staff. I also provide clinical quality reviews. So weekly, I go through every single readmission that comes back into the hospital, and particularly those patients that have been discharged and come back to us within seven days. Hospital-acquired infections are investigated, surgical site infections, any frequent ER visits. So if a patient comes to
028our emergency room and comes back again within 24, 48 hours, each of those are investigated. And then any unanticipated events are also reviewed. Once I've done the review, I'll either send it to the department leader in that area to follow up with staff if it's nursing care based or to the appropriate medical staff member to review and then either of those institute plans of correction when they're indicated. Because infection control is under the quality realm, we're heavily involved in COVID-19 support and in 2022. You know, it was a difficult year regarding COVID. So our infection preventionists would take all intake calls from employees if they've had symptoms or exposures. And we would assess each case to see whether they needed to get tested, which we did in-house. And then myself or the infection preventionists would
029follow up with staff regarding their results and a plan for return to work, always following the CDPH guidelines. There was always close communication between myself and the department leaders regarding a return to work plan for their employees to try and minimize its effect on staffing. For the majority of the year, we had weekly infection control committee meetings, which involved all of leadership to discuss staffing concerns regarding COVID, how many patients we had in-house, supply chain issues. Towards the end of the year when... our numbers started to decrease a little bit. We changed to monthly infection control meetings or bi-weekly. And then collaboration with the chief medical officer and other leaders in the hospital to revise and update our COVID-19 policies and procedures, which happened on a frequent basis because CDPH were changing their guidelines. I'm
030also involved in peer review support. So either through those clinical quality reviews that I spoke about regarding readmissions, ER visits, if I find something that needs to go to peer review, I will forward those on. We also get an opportunity for peer review through patient grievances, referrals from other medical staff members or staff. I fill out a peer review form with the information on what needs to be reviewed, and then that gets sent to the appropriate medical director, whether it's the ED. medical director, the hospitalist medical director, or the surgery medical director. This is really allowed for a robust peer review process. On average, I would say there's one to two peer review cases per month that is then reviewed by the medical executive committee. Results of that review are then shared with the provider
031that was involved via a follow-up letter, but also the medical directors have one-to-one conversations with that provider. And that letter includes the outcomes of the peer review and any recommendations that the med exec committee. decide. We also are the driving force for grievance and risk management support. So any patient grievance or a complaint are investigated immediately upon receipt. And they can come in all different forms. Sometimes it's a letter, sometimes it's a phone call, sometimes people come into the hospital. So patient grievances need to be followed up within seven days. Majority of the time there's a phone call. If a letter is received as a phone call to the individual, we try to close out agreements within seven days, but sometimes that is difficult because of the investigation that needs to occur. But they do
032get a letter within seven days acknowledging that we've received their agreements. And then a second letter within 30 days with follow-up on the results of the investigation and the resolution. majority of time they get a phone call in addition to the letter that they receive. And then finally, the quality department was... very heavily involved in the EPIC project. We provided direct oversight to the implementation to make sure that quality standards were met, that we were meeting our regulatory requirements as it comes to documentation, and that patient outcomes continue to be met. Cindy, our quality analyst, is really vital in providing support during that implementation and post-implementation to make sure there was a smooth transition. continue to report our quality metrics and to make sure that interfacing with any third party vendors that are involved in
033our quality reporting were secure. And then post the EPIC implementation, which is currently happening now, my department is ensuring that reports out of EPIC are continuing to be generated so that each leader of each department can continue their quality improvement and assurance activities in each department. That's the end of my report. If anyone has any questions, I'm more than happy to take those. The grievance and risk management topic. This is Bill. So, you know, maybe once every year or two or every 18 months, I might get a call. The other board members get a call or an email. And of course, we turn those right over to John. So that level of complaint. Any idea? I mean, it sounds like a very good process to immediately follow up and address the concerns expressed. But the
034ones that come in from that people probably call up the president of the hospital, you know, and find out. So what's the level of complaint or grievance, which I would suspect is exceedingly small? Do you have any insight on that? Well, John takes those phone calls and then he would forward those to me for the appropriate follow-up. I have heard from board members in the past regarding somebody that they know in the community that wasn't happy. I always ask them to get that person if they're comfortable to give me a call because then we can follow the due process. But every single complaint and grievance is followed up, regardless of which format it comes through. I guess I should ask John, any horseback kind of estimate of... The amount of complaints that you may get
035from the community is this pretty rare, low number? I will say, so I've been in my role for two years and the public feedback that I've gotten has consistently been declining such that I haven't had a comment. I haven't had a complaint directly to me in the last four plus months. Now that's not to say that they're not coming in. We, you know, probably get some, we do get them. But I would say, yes, it's been continually declining. And if you want to look at numbers, I would, I would agree with John in the last six months, we've had a significant decrease in quality of care concerns. A lot of our grievances are regarding billing, but actual quality of care and how they were treated in the hospital. There's been very few in the last
036six to eight months. much less than 18 months ago when I started. And I think that was mainly because that's when COVID was at its height as well. And that really affected people's perception of healthcare and the stress of employees, I think, also in trying to get people through the system as quickly as possible. So it all seems to have decreased significantly in the last six months. So thank you very much. Thanks, Carly. Bill, I think you have for us. recommendation about the retreat? Yes. Just according to the bylaws, the governance committee is to ensure that we have an annual board retreat. The practice was developed as per my cover message that we do this. Twice a year, actually, has been the practice, not just one annual retreat, one focusing on the interactions of the
037board amongst itself and also with the CEO. And then usually kind of a strategy meeting done in the fall. So we just didn't want to fulfill our responsibilities to recommend that the board have a retreat upcoming. And I think that's been the attention. So. So. I don't disagree with that. I guess we'd like, generally we try to have these in April. All of a sudden we're in April, so it kind of crept up on us. But I think we feel we'd like to try to stay in the April to May time frame. So look to your suggestion as to a date or dates that we would consider. Pull out our calendars or something. So, yeah. Yeah, I mean, we can do that. We're not going to do that now. Look at our calendar. We could,
038or see when people are available, whichever you prefer. You can simply send us a message or through the clerk. I think you and I can work on that. Right. OK, great. Thanks. Next one is yours, too. OK, so we can bring up that memo cover memo there. Going back just over a year or so, there's been kind of discussions. First came up with the board meeting, retreat board meeting, and then talked about governance as to what to do about terms. And so I think, again, different, and I think certainly. Judith was involved in those conversations last year. We talked about it a couple of meetings this year. And if we can just take a look at that memo, we still want to let it be very flexible in this respect, not to set any... precisely
039annual type of terms, but to acknowledge that, you know, people could serve on appointment up to four years. Again, this is compromise, simple language. They could serve up to four years and they could even be appointed again. We didn't say how many times. So we're trying to acknowledge that there is an up to term and insert that in the in the bylaws. So we're asking for a bylaws change here. That's our recommendation. And the wording that we suggested, we can scroll down to that. This is actually before the audit committee. Scroll up. Yeah, I think maybe you pulled up the wrong document. There it is. Okay. Yeah. So scroll backwards one more page. So it's in red right there. Well, it is. But this is, yeah, that's the language. That's where it would appear. You
040want to see the other? No, that's okay. No, there was on one version that came out, the word. Actually, it is. It's not supposed to be advisory committees. It's supposed to be standing committees. So when we talk about in governance, we had used the term advisory committees. So actually, if you do go back to my cover memo, excuse me, the wording that the committee in effect is recommending is this. Community members of standing committees. That's the key word. Because we have standing committees, we have ad hoc committees. This is the recommended wordage, and the following page shows where it would appear. So I hope I haven't confused everyone. But again, the whole purpose is to say the terms on the standing committees are for up to four years, and kind of leaving it up to
041the committee chairs to monitor that. People may come on at different times, maybe a gap in a membership, something like that. So that's it. I would just like to say, as you alluded to, I've been on the governance committee for the past two years, and we've been batting this back and forth so many times, you know, trying to figure out those, you know, term limits and the dates of the start of your terms and all those sorts of things. And frankly, I find this to be an elegant solution. Simple. I'm just delighted with it. Well, thank you very much. Good work. Well done. Any comments about that? We have to approve this as a bylaw change. I would just motion to approve. I second. Thank you. We don't need a roll on this, do we?
042I'm sorry, Vivian. That was Wendy who motioned to approve and Denise who second. Thank you. And we do not need a roll call. So I'm going to take a voice vote. All those in favor? Aye. Anybody opposed? Okay. Thank you very much, Bill, and to your governance committee. So it's still you. All right. So it was the feeling of... There we go. Thanks. So we had six candidates considered by the board a month ago, three vacancies to fill. And I think my comments were, and I think the board concurred, that all six were really qualified. But we wanted to try to keep them engaged with us. Their letters of interest certainly indicated that. There were three people that were not selected, although we had six slots. We think we would have approved them all. In
043any event, with Graham Smith being on the audit committee and then just recently being appointed to the finance committee, he can concentrate on that. He's agreeable to concentrating on the finance committee, and he has resigned. And so we have a vacancy on the audit committee. And looking over the three other people who were under review by us a month ago, I felt that Dennis Block with the banker, and I've got his resume or CV there before you. And I think he would be as the best fit. Let me put it that way. I think. One or two of the others could have also fulfilled it. But I think giving the banking experience, a high-level experience with Wells Fargo Bank and also Bank of America, familiarity with financial statements, I think that's key. The committee only
044meets a couple times a year, but I think this will help we can keep Dennis engaged with us. And I told him I was going to recommend him, and he's agreeable to serve if approved. This is Wendy. I motion to approve. I second. This is Denise. Any other discussion? I just would say I would support him. He has attended the last three finance committee members as his resume has been reviewed for a finance committee in audit and has made really good contributions. Thank you very much. As a community member. I think it's gratifying to see this kind of interest coming from the community. I think it speaks to. the board in general but how well the finance committee has been doing and the audit committee as well so thank you thank you very much that
045word is out so all's in favor aye aye aye anybody opposed great thank you bill thank you three cut through three things here uh ben are you with us apologies i was on mute yes i am yes so i can uh Steve, this item up. It was the request of the Finance Committee to bring forward a summary that just summarized our banking relationship. So we talked through that last week, and we thought it would be a good idea to present to the board so you guys could review those relationships as well. So provided those in the memo, we do have... Ben Speggen, Norcal PTAC, Bank account specific with Union Bank, they are just going through a merger right now and provide a little bit more detail in regards to what those details are and then
046as well as some of the details in terms of those relationships and specifically what those balances are. Ben Speggen, Norcal PTAC, In terms of our general checking and line of credit, so. Ben Speggen, Norcal PTAC, I will kick it or bill anything you wanted to add. Bill Meyers, Norcal PTAC, I been I think in the. you know, concerns that have been expressed a month ago about the banking industry and followed on for a couple of weeks. I asked Ben to put a report together here so we would know, if you want to call it our exposure, so to speak, to our bank and who our bank is, sort of, that we all have that in mind. And I think, of course, there was a change in ownership here, as is mentioned, you know, as U.S.
047Bancorp is a very outstanding national organization, ranked just below, not just below, but a few billion less than Wells Fargo, but a highly recognized organization, totally American-owned. Previous ownership over decades was Japanese banks, nothing wrong with them, lots of strong support. So I think very good parentage. And we can see the balances here, the checking account. Right now, we owe them more than they'd ever owe us. So that's of some concern. We're not recommending anything here, which is saying just so that the board knows who we're dealing with and the amounts. Well, I appreciate that. Thanks for that work, Ben. Any other comments or questions about it? Okay, we'll move on. Thanks again, Ben. Oh, gosh, Bill, it's you again. Oh, my gosh. Well, after this, I can relax. So we took the draft that
048the board saw last month that John had worked up and presented to the Finance Committee. There was other work underway. But we had a discussion of that. I was very happy that the three new members that had been appointed, Bob Crane, Graham Smith, and Ed Case, actively participated in the discussion. And I think there was a feeling that the draft that which we saw, we felt there could have been more quantitative detail. Again, but it's not supposed to be a business plan. But I think they were hopeful. And others said the same thing. We would want to see some more quantitative detail or reference. We were assured that as proposed initiatives would come up, that they would be discussed with the Finance Committee and be very thorough. And reference was also made to... really excellent,
049I thought, projections that John submitted last November when the board met at a strategy session, which was carried out to five years with several initiatives and then actually rolled up into an impact on the operating margin over five years. So, anyway, we've got a new revised expanded plan before us, but there was active discussion by finance. And again, we're happy to have John's reassurance that he'd be talking with us as any initiatives are planned out. So, I certainly invite Wendy, who was at the meeting, participated, if she has any comments. Yeah, I think very good summary, Bill, from the Finance Committee. And I surely have enjoyed participating in the strategic planning part. And I thank you, John, and re-ask that as initiatives come forward, and of course, there is the threshold, as you noted, the
050$100,000, that those come to the Finance Committee for just review and diversity of thought and voice and challenging around the initiatives before they move forward. Okay, with that, John, I think we can go on to the strategic plan. So as noted, we have spent considerable time refining and clarifying and researching the plan that you're going to see before you. We went out to the community. We held listening sessions. We met with key community partners to get their input. You got it? Okay. So unshare and reshare. There you go. All right. So we will move through this. This is in your board packet. I'm not going to go through it page by page. But you'll see through the document a restatement of our mission, our visions, and our values on page two, a primer on page
051three of what we're presenting and the key components. There at the bottom, you'll note the four key components, realigning our main campus, bringing care into the community, ensuring financial stability. which is, of course, important to ensure that we continue to provide care, and then meeting ongoing seismic requirements as placed by the state. The following page kind of highlights what we heard. So in those community listening sessions, we really opened it up to the community. We had great attendance, both from virtual sessions that we held, sessions we held at the hospital, at Vintage House, at St. Leo's over on the west side. So we held a lot of different venues to invite the community to a pine. And you'll see this sort of word scramble are the key themes that came out of that. And they
052are threaded through the four initiatives you'll see on the next page. We have lovingly called this our rainbow of different initiatives. The first being realigning our campus on the left side there you'll see. The objective is to ensure that the hospital, the assets that we have meet what we see as the coming demand both voiced in the community and expressed through data that we see claims data that sort of tells us where folks need care and where they're using care today. So the realignment really focuses on furthering our partnership with UCSF to redevelop the resources and the campus to meet the diverse needs in the community and the noted aging of our community. Some of the outcomes we expect to see from this are increased capacity to allow residents to access more hospital-based care. Increased
053access to UCSF providers. Improve outcomes through better coordination and navigation between care providers. Expansion of community services such as education, training, and support services. and then improved cultural sensitivity through our diverse and aging populations. The second, and I'll pause there because the remainder of the document goes through the specifics, which I'm not going to go through here. We're just going to use this page as our guide. So I'll pause there for any questions or comments from the board on that realignment strategy. There's a lot in this, I know, and we've iterated through this quite a bit. As Bill noted, we have added some specifics, some dates to some of the strategies within the document so that there's more specific, you know, sort of touch points as we go. And as you, Bill, noted, each of
054these strategies, the orange, the green, the purple, the blue, all have specific tactics that will spawn business plans within them. So there's a lot of work yet to come on these details. I'm going to keep moving the green, bringing care into the community. One of the areas where we really feel there's an opportunity is to align our care and make our resources more available to community members. If we are engaging and providing care closer to home, there's less likelihood that people are going to end up in the emergency room or being admitted for avoidable care. So one of the things we're looking at is where we can provide more available care outside of the campus to again make it more available. A lot of examples of this, but a lot of it stems around primary
055care and specialty ambulatory care or specialty care specialists that you would access in the community. We don't, through the board's direction, it wasn't too specific on what this would be yet, but we committed or we're committing to exploring different pathways to ensure availability all across the valley to ensure that people can have access to care at the right place at the right time, you know, in the right venue. The third, that purple column, is our sustainability, our financial insurance, making sure that we are able to meet the needs and pay for the services that are provided. And I do want to note and appreciate the community support of the parcel tax, which is a key component of ensuring that we are financially viable today. That tax was approved for 10 years at the existing rate,
056which means we're going to need to become more efficient to make sure that we are sustainable. As things become more expensive, we're going to require more revenues. And I'm expecting we're not going to draw that from our community, but draw that from the care that we provide and through our insurance providers on the other side. The initiatives in here are a lot of our short-term initiatives, operational initiatives, building on the services that we already provide, the services that are already in demand, providing more of them, making ourselves more available, and billing for those services to Medi-Cal, Medicare, and our commercial insurers. And then the final column here is seismic compliance. Again, the state is continuing to increase The seismic requirements, a great example, you know, the state requires that we today be able to withstand
057a major earthquake, which we can. The hospital is probably the safest place in the valley in case of an earthquake. But the next phase is requiring us to not only withstand, but then also guarantee that we are operational. which I cannot guarantee today. And so there are specifics within that regulation that we are working to meet. That is going to be a tall order. There's a lot in there. And so we're working to make sure that we are compliant. Again, there's a lot behind these four within the plan. But I'll pause there. That is, those are the four sort of areas of focus that we're proposing within the plan for the next five to seven years, because the seismic component goes through 2030 when the next reg takes effect. So questions, if there are any.
058John, this is Wendy. Yes. Comment. First of all, I applaud you and your staff for doing the listening sessions. I just, it warms my heart. And this one page on what we heard is really powerful from my perspective. Bill has suggested multiple times that we get some quantitative. I'm sorry, quantitative measures for each one of these strategic pillars. You might want to think about baselining these with a survey. What's the trust of the community today? You know, what is the diversity of our population? And then every year, you take another survey to see whether this strategic plan. is marching towards what we heard from the community. And I just think it would, I think that in itself would build trust with the community. But again, I just applaud you for the listening sessions. It really,
059for me as a member of the community, warms my heart that you did that. Thank you. Do you have any other comments, Bill? Do you have anything about it at this point? Yeah. No, again, I would applaud, you know, the overall format. And its organization, you know, these four pillars and the pages that followed. And I think, you know, we had comments a month ago. You clearly listened to those and made some adjustments, so to speak, qualifications. And also, I think I really do applaud the great effort you made to go out and listen to the community. I think that was really outstanding. I do hope that. implied here, you will be receptive to suggestions that may come from one quarter or another about new service lines. We've spoken about this before. Those are marketing
060and business risk challenges, no doubt, but I think we need to again. trade on and leverage Sonoma's unique location. And I recognize you have no doubt about that. And it also goes to staff, hiring people, clinical or administrative staff, as well as an appeal to out-of-district patients. So be looking for that. Also happy to see here on the four-column page, number five. planning for increased utilization of the hospital services, especially surgery. We've talked about that before. We have. Very important that that be done because those surgical volume increases will bring their added revenues at hopefully different margins, positive margins, that will support everything else that we want to do for the community. Then one other comment I'd make, which again mentioned before, is to try to identify where is the population in this district. There
061are only 10,000 people in the city of Sonoma, so it's to the north of us for sure, and also around the west. And as you develop your initiatives, those plans to get a better fix, or not a better, but to get a fix on where the households, where the people. But again, and I applaud your particular identification of the senior population, obviously, and then also of the Latino population here implied throughout. So very good. Thank you. Denise, do you have anything you want to add? No, I just agree with everything that's been said, but I just want you to know that I think this is a really nice document. It presents well, it's very powerful, it's nicely organized, it's easy to understand. I think that the community is going to be very receptive to what's
062in it, and I just really appreciate the work that's gone into it. Great, thank you. I'd like to add, this is not the first time we've seen this at all, and it's really been fleshed out, and I appreciate that. extra effort that you that you put in so thank you and I'll reflect that back to the board obviously you put a lot of effort and time into giving feedback and thoughtful you know constructive feedback and the team worked with that so it's a reflection not of just us but of the whole group well thank you yeah so I guess the question is what's what are our next steps what do you envision Well, I think the board should accept this. I'd make a motion that we accept the report as submitted as our strategic plan
063for these five years out. I guess I was talking just in general about once we accept it, we're going to accept it. Where we're going to be going next, that's all. Well, as is outlined in probably a third of the initiatives in here, there are targets for the next six to 18 months. Great. So those are our starting points. And we'll be working each of these and you'll start to see business plans submitted for various parts of this plan. That's what we want to hear. So do I hear a motion to approve this? I move to approve the strategic plan. This is Denise. I second. This is Wendy. Those in favor? Aye. Any opposed? Okay, so it passes. Bill, excuse me, John, thank you again to you and your team for all this work. We
064really appreciate it. You're welcome. Thank you. Now we have the CEO report. Thank you. And I'll be brief with this. You'll see the document in the board packet. I'll note we continue with some COVID and flu as the spring continues. Volumes have been down over time and they continue to be relatively low, but it continues to be there. And I'll note. that we have probably almost to the three-year anniversary now revised our COVID protocols in the hospital, effective this last Monday. Our masking has changed. And it's interesting to reflect it's been three years. Operationally, the organization continues to function well, and you'll see in Ben's finance report that volumes and financials are solid, are strong. We are awaiting our triennial quality survey any day now. We expect to get great feedback from that. It's always
065a constructive process. But as you saw in Kylie's report, the quality of the organization remains strong. Finally, and this is I'll take another agenda item off this, our capital update, the ODC project, the second phase of the ODC project continues on time. The temporary MRI is in its review with the city. We're actually going through over the next few weeks, our listening session with our neighbors to make sure that we inform and listen to them as we propose to make modifications to our campus. And we expect the temporary location, as noted, to be live by the end of the year or early January. EPIC, we're in month four now. We've just completed month four. Project goes well. Again, the only remaining significant component is the interface with UCSF. I've just completed. conversations about that, and
066we expect that to be live or completed in early July. It's about a 90-day effort to do the work to get that interface completed. So we expect that to be done in early July. That is my report, unless there are any questions. Thank you, Judy. Thank you. So now we have the pleasure of hearing a... a report from our first really official formal report from our new chief medical officer. We've welcomed her and are really looking forward, Sujatha, to hearing from you. Thank you. Thank you. And I will go ahead and share my screen. I'm happy to give this report. So a lot of what I will address we've talked about, so I'll move quickly through some of these items, starting with clinical updates, and then I'll talk a little bit about subspecialty access, and
067then a geriatrics program that we're beginning to build, and then our efforts around diversity, equity, and inclusion. So as you heard from John, we've had a change in our COVID guidelines, and this is one of many that have happened really just to coincide with CDPH changes. And really, the biggest thing is that now we're strongly recommending masks rather than requiring them. But most other other guidelines have remained the same. Second clinical update, we've been working, the emergency department and hospitalist group have been working on thinking through how do we address patients who are in the emergency department, who are waiting for admission, who are going to be admitted but don't yet have a bed in the hospital yet. And in the past, what would happen is we would wait for them to get a bed
068before we actually started their admission care, before we activated their admission orders. So we've implemented a change now where we are. boarding these patients in the emergency department, even if a bed is not available, and activating admission orders there. And this is really just a mechanism to streamline care and make sure that they start getting care if they're going to be admitted while they're in the ED rather than waiting for a bed to be available. So this is a new process that we've put together after a number of meetings, and it seems to be going well so far. And then the last clinical update is around Epic. And you've heard a little bit about. you know, how things have been going, mostly been going very well. I think as we're now moving forward, we're trying
069to really drill down on some of the specifics and some of the benefits that Epic offers. And among those are the templates and order sets, trying to make sure that everyone is using templates when providers are writing notes in the chart. So we're standardized. And the order sets that Epic offers are actually quite powerful. And so we're really making sure that people are using those order sets because they really, when Kyle really talks about quality of care, the order sets can really help streamline and standardize what everybody's doing. We talked a lot, I know, and you had a closed session about the ED and what the process has been. Just to delineate the process again for this EDRFP, there was a request for proposals that we put out in January. Four groups submitted proposals. I
070met with them individually. Then we had a selection committee with good representation from throughout our staff. And then we asked two groups to return, and then we chose the Napa Valley Emergency Medicine Group. And we're now pending approval from you all, really just getting approval to negotiate with them and see if we can come to an agreement with them. So that's where things are at right now and really excited about this process and the progress we're making. Other subspecialty areas that we've been thinking about, and I know you've heard a lot about GI and thought a lot about GI, where this process is right now, we've been working with UCSF, and there's two potential pathways. One is through the UCSF BCHO Foundation, so potentially recruiting someone through that mechanism, and we're going forward to try
071that. At the same time, I've been meeting with the chair of GI at UCSF, and they are interested in potentially having a shared faculty role. This would be a person who's a faculty member at UCSF who spends part of their time at UCSF and part of their time up in Sonoma. So a little bit different of a model, it would be somebody who would have both a community practice and an academic practice. It's not clear that we'll have candidates who will be interested in this, but this is something that we're trying and we're keeping all options open as we're trying to get some. EICU is something else we've been thinking about. So in terms of providing support to the hospitalist group in the emergency department, really as patients come in who are sick and we
072don't have an intensivist on staff, we've been thinking about ways in which we can have remote consultation for ICU patients. looking at different models, including a model that the hospitalist group themselves would help with. There's that company that staffs the hospitalist group right now. They actually also have an EICU service. So we're working with them to think about, can we use that service versus finding another one? So that's in the works. And then finally, urologist coverage. We are working on inpatient consultation via telehealth. So patients in the hospital who need urology consultation could receive that, that the providers could get that consultation through telehealth. And then Dr. Carroll, I know this has also been in the works for quite some time, but he is planning on starting July 2023. So coming up here and initially
073it will be completely via telehealth. The patient will come into the hospital. They'll be checked into a room and he will see them via telehealth with the goal of transitioning to partly telehealth and partly in person in the next couple of months following that July launch. I'm going to just quickly tell you about two programs also we're working on. So one is the geriatrics program. So this initiative is really to transform Sonoma Valley Hospital into an age-friendly health system, which is a term that's used throughout the country for hospitals that really have services that are geared towards geriatric populations. And given our patient population, we thought this was a great initiative to really think through and really think about how can we make sure the care that we're delivering is consistent with geriatric best practices.
074We've convened a multidisciplinary geriatrics committee. We've posted for a geriatrics nurse practitioner. We've interviewed, we've started interviewing candidates and we're in the process of trying to select somebody. We will have a geriatric nurse practitioner who will. Basically, their role will be to see preoperative geriatric patients, but also provide inpatient consultation on geriatric patients, and then at the same time help build the systems to provide better geriatric care. So things like order sets around decreasing rates of delirium in the hospital, education for staff, and importantly, provide outreach with community geriatric resources. So it will be, you know, we'll start with this one person and then hopefully, depending on how that goes, we will grow the program. So that is in the works. And then finally, we've launched some efforts around DEI, so diversity, equity, and inclusion.
075We have a DEI committee that we've convened. We're really thinking about a few different areas initially. One is around social determinants of health. So CMS is now requiring us to screen all patients for certain social determinants of health. So these are things like financial status, housing security. food insecurity, these kinds of things that affect people's health, but that are social factors. And we are thinking about ways in which we can implement this screening. Epic does have the ability to record some of these things. And so we're thinking about what is the best system for that. So that is one DEI related effort that we're embarking on. Also DEI training for staff. We're looking into different options for training and then looking at a lot of our quality metrics with the lens of. of race and
076gender and other demographics. So really starting to think about how do these factors impede and affect care. That's all I have. I'd love to entertain questions if people have any. Pages, please. Sujata, can you hear us? Oh, I missed that. Sorry. Can you put your slides back up? Oh, sure. If you could go back a couple to the geriatric, yeah. I frankly think this is really exciting. This is a huge need in our community to be addressing this age-friendly, in an age-friendly way. I'm curious about who is on these committees, the Geriatric Committee and then the DEI as well. Who's joining you in that? Yeah, so we, you know, we have a pretty broad group of people on the geriatrics community committee. We have some community physicians. We also have our, you know, the Jessica,
077chief nursing officer, Kylie's engaged in this. We have some physicians from the hospitalist group. We have Alexis, who's a general surgeon. So we have sort of broad representation. And I think. An area like geriatrics, really, it affects, you know, affects every specialty. So you sort of think about preoperative patients, you think about patients in the OR, you're thinking in the community setting, primary care. From a nursing perspective, there's a huge, you know, need for education. And so there's really, it really requires having a kind of multidisciplinary, multi-specialty group. But there's been a lot of interest. I've been really pleased with the amount of interest. I'm not surprised that there's been interest. And I think having a nurse practitioner take this role is a great idea. The outreach was a community badly needed. So I'm very,
078very pleased. This is Denise. Have you thought about partnering or speaking with the villages effort, the villages of Sonoma Valley and what they're doing to support the geriatric community? I haven't. And I would love to hear more about that. Yeah, let's talk about that because they're a great community group that is focused on delivering services and really focused on social determinants of health for this community. Yeah, love to hear more. Well, thanks very much. This is Bill for this report. It's very encouraging. This is the first time I've heard. of a program like this at this hospital, a real targeted clinical effort to a very important demographic in our community. I would just suggest that you also take into account somehow in discussions with John, the marketing of these capabilities, extremely important. that people know
079about it. Sometimes we do things like going way back years ago, obstetrics, people didn't even know we had it. Won't go into that story. But anyway, I think this is going to be something to really talk about. So I think communications in many forms would be very, very good, whether it's a an old-style pamphlet or brochure available or given to people if they fit the demographic. Web page, of course, highlighting all of this. And as to the committee, you may want to talk to, well, of course, to John about whether Celia Cruz de la Rosa can be involved with this. I mean, she has the connections to... vintage house. And I think they should be a partner in this. I mean, this is the meat of it is the clinical approach and undertaking that. But
080the other part of it is to be outward facing to the demographic. And that's got to be highly emphasized. So I would suggest that. But otherwise, very good news and compliments to you for conceiving this. Thank you. That's very helpful. This is Wendy. I have a comment and then a question is I just wanted to applaud the DEI work that your program and I see a direct correlation between that program and you may want to link it to, I always call them pillars, but the second pillar of the strategy, which is bringing care to the community. I just think doing that in a way that's under the umbrella of DEI, again, will build trust. and, you know, use of the hospital. And then second, I have a question, real quick one was, what was the
081trigger for re-looking at the ED admission protocol? I mean, what I want to infer from that, but that there was a long lead time to get beds, or maybe I'm... Yeah. No, I think that's a great question. So I think largely the issue that was coming up was when you would have a patient who would be, you know, who, where the decision had been made to admit the patient, but in cases where a bed was not available, as you said. that patient would sit in the emergency department and often their care would not be initiated. And so there'd be a delay in care. And so we were seeing a number of cases like this where there's a delay in care. And so that kind of coordination where we really think about the patient independent of
082where they are in the hospital, their care should be what it should be. So if they're an admitted patient, they should be getting that care, even if they're physically still in the emergency department. That was sort of the guiding principle. And there were a number of cases that were coming up. And so that's what led to this change. Thank you for that, and thanks for taking the action. And for letting us know. Okay. It was really nice to have a good, complete CMO report. When I read it in the minutes, I thought, boy, she's got a lot to tell us. And we really appreciate it. John, I think you're next with the UCSF affiliation update. Yeah, the Joint Operating Committee matrix is included in the packet. And it outlines the basic and the initiatives that
083we are working on between Sonoma Valley Hospital and UCSF. The key. I'll wait for her to pull it up. There you go. All right. Perfect. Can you zoom a little bit? Yeah. Yes, it's a bit of an eye chart. But you'll see there are different lines here that are green, yellow, gray, and white. And the areas that we're focusing on right now are the green ones. You'll see that's perfect. I think that's great. You'll see that the green ones are the ones we're actively working on. As Sujatha talked about, the intensivist coverage of our ICU is a high priority, and there's an opportunity potentially to collaborate with UCSF. We are working, again, collaboratively with UCSF on the recruitment of a GI specialist, which has been top of our list of needs in our community for
084the last four years. We are also issuing an RFP to UCSF for new programs that might be of interest to the faculty at UCSF and also of value to Sonoma. So we'll be looking over the next nine months at getting proposals from faculty members on programs that might apply to Sonoma. Down lower, you'll see the next green area we're focusing on. Down here at the bottom. Yeah. Is leadership development. And as, as Wendy noted, a key component of being successful as a community hospital is engagement of your community. And that starts with your leadership and ensuring that your leaders are aware of your. initiatives and purpose, and then are engaged in the community. And we have a wonderfully engaged leadership team. But that only continues if you continue to feed it. And so as Sujatha
085talked about, we're looking at DEI training. We're also working right now on conflict resolution training, just to make sure that we continue to feed the leadership of the organization. I won't go through the rest of these, but there are a lot of other initiatives within this that will be pending as time goes on. Thank you. Any questions about that, Wendy? Could you expand on the one at the bottom, the joint venture opportunity? Either I've missed that all these months or just say a little bit more about that. 5.3? Is that what we're looking at? Develop a business case for joint venture? Yeah, that is something that is not active yet. It's something that we're putting on the burner to be developed. That is the potential to realize future growth with the support, the financial support,
086and potentially the clinical support of UCSF. Thank you. And then just a suggestion, maybe use this format for your initiatives for the strategic plan. Sure. Yeah, good idea. Because we're really familiar with this now. Yes. Did you have anything more to say about EPIC? I didn't think so. And that means it goes to you, Ben, for financials. Sure. Thank you, Judy. Monique, are you able to pull that up on the screen? Let me know if... Perfect. She's pulling it up. Perfect. So, yes. So as Monique's pulling it up, I will try to be pretty brief with February's report, I think, all in all. February is a very positive month for the hospital financially. We've been live with February marks three months since we've been live with Epic and we've exceeded budget every one of those
087months. So certainly a positive. And then I think for February specifically, it was the best financial month that we've had this fiscal year. So certainly I think, you know, trending in the right direction. You know, certainly where we, this isn't where we want to end up, but I certainly think it's, we're moving on the right path. I think from a volume standpoint, you know, we continue to see steady volumes, particularly on the inpatient side and inpatient surgery, especially with general and orthopedic surgery. And then we continue to outpace, on the revenue side, we continue to outpace budget in the prior year. I believe we are up 8% in revenue year over year. And we've been actually in the operating expense that we've been able to pare down some expenses since Epic. And in February, we
088ran 6% under budget in operating expenses. So all in all, I think a really good month. And I think, you know, to kind of top it off, we had a really good month in cash collections in the hospital. So we collected $4.2 million in February. That is nearly 50% more than what we actually had expected and that was on our cash forecast. You know that again, you know the 4.2 is a little bit higher than our historical baseline. You know, so some of that is catch up because we ran under these past couple months, but certainly that is great to see. And actually, you know, you see that on the cash forecast, you know, our day's cash ended up much higher than we had initially projected. So certainly some really positive movement there. I think
089on the epic side, you know, we're able to now kind of make some headway. There's still quite a bit to do in terms of working through a lot of the kinks on the revenue cycle side, but things are starting to move and we're starting to see that financially. So certainly that's been great to see. So I will stop there. I'm happy to answer any questions that you all may have. Correct to infer that cash receivables are. better because denials are down as a result of Epic? That is a really good question. I think certainly that's part of it. We don't want to get too much in the weeds, but I think in our Paragon system, it was difficult for us to really kind of track the denials due to how I think our business office
090would work them. I would say, Wendy, certainly it's put visibility on some and it's allowed us to really work through them very quickly. So, you know, it's hard to kind of compare what we're getting out of Epic to our baseline. But I would say certainly, Wendy, you know, we're seeing those and we're addressing them as fast as we can. And I think it's given us a line of sight that we just didn't have in Paragon, which actually is, you know, one of those things that for us, it gets really exciting because it allows us to identify the problem much easier. But I think now that we're in EPIC, to your point, Wendy, I have thought about it would be good to start including some of those metrics in the report now that we're getting that
091data through EPIC. So we can plan on reporting on that in months ahead. That's great. Thank you. That's it from you, Ben? Yes. So any board comments? I think we're through. So do I have a motion to adjourn? I move we adjourn. I second. Those in favor? Aye. All right. Aye. Great meeting. Very good.