001A member from the public who's just joined and the question was do we have any members from the public who have comments on any topic that is currently not on the agenda? Hearing none. I'd like to start off the meeting with an introduction. I've done this now three times this week. It is an honor to have Kelly Kaiser join us today. She's here in the audience. She is our new CEO of the Sonoma Valley Hospital. So welcome. Thank you for being here. All right, we'll move into consent calendar. In the consent calendar, we have the board minutes from October. Quality Committee minutes from August. Finance Committee from September. A stack of policies and procedures and the medical staff credentialing report. Any questions, comments? If not, can I get a motion to approve? Second. I second.
002All in favor? Aye. Aye. Any opposed? No. All right. Next we have, it's great to have Dr. Amara here today. He's going to be doing the Chief of Staff report. Thank you for joining us. My pleasure. Is this mic working? There you go. Yeah, it is working. Yep. So this is the Chief of Staff report from, I became Chief of Staff in July, so it's from July to October. First of all, I'd like to just say that I want to acknowledge Dr. Akko Walter, who did a wonderful job as Chief of Staff over the last two years and really fostered communication between the staff and the leadership. I'm hoping to emulate that. Today I'm not going to go into specifics about numbers of doctors who came on to staff and left the staff. I'm just
003going to talk in general about medical staff issues and how things are going. But I do want to reassure the board that the quality of the medical staff remains very high. But the nature of medical staff has changed over the last... couple of decades it used to be we'd have primary care physicians who would then admit their patients to the hospital and follow them in the hospital that's long gone by the wayside and now we have a hospitalist group who admits most of the patient we do have a couple physicians who still admit their patients but that's the exception rather than the rule and that has led to less engagement of the primary care physicians with the hospital because they're not there hospital contracts with multiple groups of physicians emergency room physicians anesthesiologists hospitalist group
004pathologists radiologists so these are all contracts that bring a whole group into the hospital But the issue, I think, is really in terms of the physicians in the hospital or the physicians that aren't affiliated with any group. And those are generally the surgeons or the medical subspecialists like cardiologists. And those are where you have to focus, and we have to focus if we want to retain and develop services because the other groups we don't have to recruit because we have standing contracts. And so that's an issue. What percentage of the staff falls into that category? Into that small category? Small category. Well, it's a minority. Yeah, I mean. But they are specials. Probably less than 10%. But you have to look at it. I mean, we have telepsychiatric consultations and things like that. And then
005we have nighttime radiologists and things like that. So the numbers go up. But in general, our groups, the group physicians are excellent quality. And they've maintained that throughout my experiences here. But really in terms of what's going to affect things in the hospital, it's this small group of physicians. So the hospital district's mission, and I'm going to paraphrase it, is just to maintain and improve the health of people who live in this area. And so it's not just the hospital, even though the medical staff is in the hospital. So I think of all of the primary care physicians in the community, and that is another area where we have to really focus. There are very few... solo practitioners left in the community and it's very hard to compete with Foundation models which are pulling physicians
006away out of residency and things like that and so I Over the last six months. I've had many patients say when I've asked them well, who's your primary care physician? I want to send a copy of this note to them. They've said no one I don't have a primary care physician and other patients are going out of town They're going to Napa and they're going to Petaluma Santa Rosa Marin and even then There's great turnover. So I think that is a crisis for this hospital district because they're fundamental. I also work at Sonoma Valley Community Health Center. I've been the director of OB there for about 28 years. And I see them as fundamental. They have an enormous panel of patients who are underinsured and many of them are non-English speaking. And so I think...
007That's a very important relationship to nurture, and that helps maintain the hospital. I can't imagine if that system failed, that would swamp the hospital and not make the hospital viable. So just to go on to other medical staff issues, just reviewing the main committees. The primary committees are the Medical Executive Committee, the Surgical Committee, and the Medicine Committee. Recently, in an effort to... improve and reinvigorate physician quality, we've created a quality review committee. And that consists of, it's under the chair of the vice chief of staff, currently Alex Reynaud, our cardiologist, and has members from surgery, medicine, anesthesiology, and ER on there. And that's a way of being more efficient. So I'm very excited about this, and I think it's going to improve quality and continue to improve quality. I just want to acknowledge Dr.
008Cusick, who did an excellent job as our interim chief medical officer, really did a great job. And I'm ecstatic to welcome Dr. Patrick Okolo as our new chief medical officer. From what I've read about him and my conversations with him, he seems to have a lot of experience in quality and administration, and those are things that we're going to need. And also he's an endoscopist and that's one thing as a surgical specialist that we need. So I think eventually we'll get him into the OR and doing procedures. I'd like to welcome Kelly Kaiser, our new CEO, and a brief conversation with her and reading about her. I think she's got the experience to help us deal with this changing environment. And then I'd also, I don't know how many people know, but Sonoma Valley Community
009Health Center has a new CEO, Sarah Brewer. and she came on recently, and I'm excited to work with her as well. So we basically have three new leaders in our very small local medical staff or medical leadership. So challenges. So I'm just going to, and these are things you know, but I'm just going to touch on them from my perspective. The major one, and I've mentioned, is recruitment and retention of physicians, primary care and specialists. Currently we have a... 12.06b clinic and that's useful in maintaining some of the primary care physicians and transitioning primary care physicians are near the end of their practice. We also have one surgeon who's in that group. It's an interesting model. It's a hybrid model. It's not a turnkey model where a lot of residents coming out or physicians and
010you want to come to the area would move in and say These are my hours, these are my benefits, these are my vacation. It's a little trickier than that. So I think that is a major challenge for us because we're competing with the foundation models. And just bringing that up, and I'm sure everyone's aware of it, but I think that there's a crisis in terms of primary care physicians in the Valley, in terms of the lack of them. And then another... issue or problem is really coordination of the system. So we have a relationship with UCSF, but we have to think about what we get out of that relationship. Certainly we get some things out of it, but can we leverage that to get more in terms of... Transferring our patients when they're critically ill
011to UCSF. Is there an easier way of doing that? Make it easier in our hospitals, in our ER docs? Improve the quality? Could we use them to somehow recruit primary care physicians or other physicians to this area? Help leveraging that? Maybe Dr. Alcola can help us with that. And then other things we have. We have relationships with the Providence hospitals. We have a major Providence hospital to the east and another one to the north, and they influence our transfers and also our hospital care. I'm an obstetrician, so I no longer deliver at Sonoma Valley Hospital because we closed our unit in 2018. So I'm at both of these other hospitals trying to manage patients that are here in Sonoma. So the final thing to comment on is it's more... nebulous and daunting is really the
012economics and the politics of health care. And I don't know that we know where things are going in the future. I mean, the reports, you know, Ben has, you know, presented, it seems like the hospital's in stable financial shape, which is great. But, you know, the future is very uncertain about what's going to happen and how care will be reimbursed. And I think one of our strengths, we do have a very cohesive medical staff group. And many of us have been through things, and we've been through health plans that have gone bankrupt. Just today I got a letter from Meritage saying that they were gone, and they can't pay the bills from this year, essentially. And you go to their website, and it's closed. I think, and I remember going through this in the past
013with Health Plan of the Redwoods, as many of our older physicians do. So it's just something that's repeated, but it makes it difficult as an independent physician. So I think that is a serious problem. But that's something that our cohesiveness will help in our working closely with our administrators, because that is something that... we're going to have to respond to and no one knows really how things are going to develop. I'd be happy to answer any questions. The lack of primary care physicians in the Valley, so Sonoma specifically, the Valley generally, how does that affect us positively or negatively? You said negatively, but how does it affect us? Oh, definitely negatively. Well, I mean... It affects the quality of care because people aren't seeing their physicians. People are going out and then it affects the
014hospital system economically because when people do go to see primary cares out of our system, out of our local system, they'll be referred to other places, say for colonoscopy or things like that, services that we have and we're trying to sustain and develop. And it's just not great care. But it's not unique to Sonoma. It's unique. It's everywhere. But in a small environment like this, you know, you lose a few primary care physicians and it's devastating. So partially, without primary care physicians, and I respect your point that they can be referred externally, we need to get the message out to the community of what services that we can provide here. So even if they go to primary care outside of our valley, they can still get referred. That's true. So I think that's a marketing
015slash communication response. Yeah, but I think there is a tendency once you go out to get referred out. I mean in terms of like mammography since I see so many women from the valley I can keep them in the valley because I think our radiology group is excellent. Remind them that it's not just a small radiology group here It's a larger radiology group that covers multiple hospitals and has expertise in several areas. So I try and keep that population here but when people go out and it's it's much easier for people to the Primary care is to follow their habits right and they were for people they're used to referring them locally anything else I just question Dennis and I were actually just on a meeting an hour ago speaking with UCSF about the affiliation
016agreement. And two specific areas we brought up that we could use their help with was transfer patients, which you mentioned, and also physician recruitment. Is there someone by name you would suggest we work with in the medical group? to get some focus on those two areas? To work with locally? I think I'd go through our chief medical officer initially. So Dr. Okolo, okay. You got tagged, yeah. And we can also go through the med exec committee as well. But I think we all realize the problem. It's just a question of how to solve it. Right. I don't think local conversation, they're having the same troubles. Yeah. No, it's true, and it's harder, even though we live in a beautiful part of the country. If someone's coming out of residency and they're, people want to, nowadays,
017they want to plug into a foundation model, I think. A lot of them come out thinking that. They want defined benefits, defined hours, and things like that. Physicians are not, they're different than they were 30 years ago when many of the people here started. Just something to keep in mind with regard to Meritage. I know my husband, he received a notice, and he's been given a new primary care physician not in the town of Sonoma. Yeah, yeah. A lot of them transitioned to Providence. So this is probably happening a lot. Oh, yeah, yeah. And I'm solo practice, so I've signed up with everyone. Great. I can see Providence patients. And I'm sure that there are a lot of physicians in the area that can see anyone, but the fact that they're referring them outside, you
018know, out of town is, there are options. I mean, of course, I told them, yeah, to find a primary care in town, but. Yeah, I think the issue gets even more complicated for the Medicare Advantage plans. Aetna will not be in the market next year. Anthem will not be in the market next year. There's only six plans. Three of them are Kaiser, Sutter, and Imperial is the only one that isn't tied to an existing network. So it's also going to create some potential disruption. Okay. Well, thank you. All right. Thank you very much. Right next we have Leslie. He's going to give us an update on the... Foundation. Hello everyone. Thanks for having me. Whitney has my slide deck and I live by the slide deck. So waiting for her to get that up. Can
019you? There we go. Now because I can't read it when it's that tiny. You can hit the next slide Whitney. So thank you all for having me here. I'm excited to be here. I'm, I think, 11 months into my role here at Sonoma Valley Hospital, and I am extremely happy to be here and be a part of such a great community resource. So in coming, traditionally the foundation has raised funds for a capital project. And since I arrived until October, we didn't have a specific capital project identified. And so in being around the community and talking to people, I kept getting all of this great feedback about the hospital and the work that is being done there and the care that people received there. And we really decided we really need to get that out.
020right start telling those stories in the community because for as long i've lived here since the 70s and um you know the hospital's had its ups and downs where the community didn't see it as so positively and so really just to get the word out about the positive work that the hospital is doing we decided to launch this campaign which is called the my hospital campaign hopefully you've all read the stories and receive are receiving the stories by mail or in your email inbox or have checked them out online. But we've launched that campaign. We started launching that campaign in July. It's monthly stories that we send out each month about people in the community and tell their stories. And in that, one of the goals was to raise unrestricted dollars. So... Traditionally, we've raised
021money that's restricted to one specific capital project. And with this campaign, our goal was to raise more unrestricted dollars. So as you can see from the slide, we've had more than 50 gifts given between July and September. And those gifts in total raised $280,000. And of that $280,000, $274,000 was given. without restriction, which is great because then we could spend it on whatever we would like to spend it on. All the things that are not what we call sexy in the business, right? Like if we wanted some air handlers or a new saw or something that doesn't sound really great or is a little hard to pitch, or maybe it's smaller than what we would want to spend on a capital campaign, we were able to raise those unrestricted dollars. Next slide, Whitney. Hey, Lizzy,
022is there any way to understand the donations that have been given directly as a result of the My Hospital campaign? Kind of. I mean, we send out a reply device, and when those reply devices come in, we try to keep track of how they come in. If this continues on and on, we may get more specific and target month to month which stories resonate with people more than others. But so far, we are able to kind of identify them. They usually come in shortly after we send out a story, and then we'll get a week or so of... funds that come in. So how we've been getting that out through distribution, hopefully you've... either got in the Sonoma Index Tribune or you've seen the ad in The Sun. It's also in the Kenwood Press. We
023were doing advertising in the Social Publication, which has a readership of about 3,500 people. We pulled that back for a little bit just because I wanted to really get my hands around the budget and how much we had. But I think these stories, because they're stories of the community, will really resonate. So we're reestablishing our relationship with them. And so these ads will, moving forward, be in the social publication as well. Every month, I mail to our ambassadors 350 copies via snail mail so that people are surely getting them in their hands if we can rely on the USPS. And then it goes out to our email list, which is about 3,100 people. And the great thing about that is the open rate on those emails is 50%, which is how... significantly above industry standard
024for a bulk email so yeah it's I think there was one month it was 41 40 51 and one month it was 49 but otherwise the other couple months it was at 50% which is great and then we're really trying to launch social media right now. We just have a Facebook page, but in the coming weeks, I'm hoping to establish an Instagram page to engage some younger people who will eventually be donors to the foundation and then a page on LinkedIn as well. So we'll be getting that up. So share it if you don't mind sharing those stories. If you have a social media, if you have an email, forwarding them to other people that you might know. We would love to build up the subscriptions to both of our email and social channels. Next
025slide. While we were doing this, in the reply device, we give people the option of places to donate their money. And these are the specific categories that we chose to highlight and have created case for supports. So in the hospital, in the lobby, in the waiting room on the surgery floor, in the imaging waiting area. Their case for supports are all in there so people can sit when they're looking for something to read they can pick up these case for supports. I also have them in my office. They're available on our website and there are significant statements that are written so that people can make their choice. So when they these are the boxes that they have to check and how we have identified the unrestricted donations is along with each one of those boxes
026there's a box that says use where it's needed the most and that's the box that people tend to check. So that's great and we appreciate it. The $6,000 worth of additional gifts were targeted directly for the emergency department. Next slide. Spinning. So I just wanted to kind of give you 2025 to date. These are the items that the foundation has supported for, and there are some funds left in these, not a lot, but a little left because we're wrapping up all of these projects. 1.599 million that we spent or that we've... paid to the hospital for the ODC project. 1.388 million towards PT expansion. 1.5 million to date. There is some funding left in that pile that will be going. Just got some invoices today for wrapping up those projects as well as $220,000 towards
027ICU renovations. We purchased, as you can see in this picture, a new ultrasound machine, and that was from the proceeds from the Women's Health Symposium. We made about $161,000 and were able to purchase this new ultrasound. They're all trained, and it's working now, and they're using it. $200,000 from our end of the year 2024 campaign. We used to purchase a new cataract eye microscope, so that is in use now. And then $23,000 for an orthopedic saw because everyone who has orthopedic surgery wants a sharp saw. And then $11,000 so far to date we've spent towards continuing education for nursing, PT, and other SVH employees. And we get an annual gift that really supports that. So we really encourage the staff to use that to keep them at their highest level. I don't, maybe you all
028were there at the PT opening, but we held a really great opening on Thursday, October 16th, honoring our ambassadors and those that funded the expansion of the PT clinic. It was at least 60 people were there. I think there were more than that. We did a ribbon cutting. Therapists that were there did tours. And the great... thing that was a kind of a bonus ad was that we did a demo, Stryker came and they did a demo of the Stryker system that we're hoping we're raising funds for now and we're hoping to have up in the OR at the beginning of the year. we can raise a million dollars. So that leads me here to this end of the year campaign. This campaign is kind of taking our conversations for people to donate their money
029at the end of the year, which is kind of traditional giving time, and really to target it at this striker system. The campaign goal is a million dollars. So far, it's more than that today. We've raised about a quarter of it, so about $220,000 to date from a few more than 38 donors at this point. But when I put this together, it was those numbers. What we're hoping for is to have 100% participation from not only the foundation board, but also the health care district board. So whether that don't. We've set a goal for that for $150,000. It really means a lot to our donors that our boards participate in these fundraising things. So it's really great when we can go to a donor and say 100% of our board has bought into this and
030believes in this. So happy to discuss that with any of you and all of you. I'll probably be reaching out individually to set up a time to talk about how we can get you to support that. efforts. And then also we have a target list of about 65 ambassador donors that we're reaching out to setting meetings up. We've already started that and it's going very well. So we'll continue that through the end of the year. We hope to meet this goal in January and be able to purchase this striker system. Next slide. Any questions? How much is the hospital committing to it? Is there any co-payment? On the striker? Yeah. No. No, we're trying to raise all that money. That's a really great question that a lot of our donors ask. Is the hospital participating
031in this? The hospital has, my standard answer, is the hospital has a list of capital needs that it stands at about $13,000 to $14,000 million. And so if we can take $1 million off of that plate. the hospital still has $12 million to $13 million worth of capital things that it has to figure out how to finance. And so when a donor asks me that question, that's my answer, right? We're just taking this small portion of this pie that the hospital has to fund. So separate question. Yeah. Maybe it's to Ed. Even though it's not our money, you know, because it's going to be the foundation's money, wouldn't process suggest that the board should still be approving the... development of that I'm not sure what you mean by development effect but in other words we're
032letting the foundation spend money at the hospital but from a pure process standpoint shouldn't the board in the hospital approve the the initiative I think it's a it's an a management issue to bring the issues forward we have to be careful because these are two separate organizations, so while we're linked, our board, their board. No, I know, but okay, so I recognize that, but the foundation is supporting a hospital initiative, I'll say it that way. Separately, shouldn't the hospital be approving the initiative whether we decide to fund it or whether they decide to fund it? Well, the hospital did recommend Stryker. And did we approve it? I don't think we did. I don't think it's something. Well, you can go ahead. Sorry, I don't mean to cut you off, but we are going through the
033contractual process with Stryker right now, and we have every intention, hopefully, we bring it through the Finance Committee this month in November and then to the Board. But, yeah, we have every intention of running that contract through the normal process. Thank you. In the future. Shouldn't we say yes first before they start funding because if we said no Therefore they're fundraising on something that we said we don't want I think what what Dennis's question is is that of the 13 14 million dollars of capital projects his If I hearing you for your question is Should the board approve? Which is one of those capital projects the foundation? Oh, no, no, no, no, I think it's great that the foundation is raising it I'm just thinking from a pure oversight standpoint We are still responsible for
034oversight of the hospital true and No, no, I don't care how it's funded. Yeah, I think the semantic you know where I'm going I know where you're going, but I think it's a management Start there and they bring forward a capital plan we can discuss. I don't think it's something that has to come through the board. Oh, no, no. Oh, okay. So you're saying that... There's discussions around what are the big projects, and, you know, we'd like to get the foundation to fund this because... Oh, no, of course. You know, and it's the medical staff input, and there's a variety of sources. You know, it's a project that makes sense. It's, you know, it's sexy for donors. No, no, I get all that. But I don't think the board needs, I don't think this board
035needs to have their fingerprints on that. Really? Yeah. Even though the board can say no. We don't want, in our various priorities, that is just not our priority. Well, I don't think the board should be dictating the priorities. No, but they should, I agree with that, but they should be approving or not approving. I don't agree. Okay. I think management's going to do a great job of... keeping us informed on through the foundation what's going on. But I don't think it's our board's responsibility. So what you're saying, okay, if I can clarify. Sure. Because you and I are in disagreement. Sure. That the hospital decided, you know what, the board, the hospital board is not approving this, so I'm going to separately go to the foundation. And I don't think our two organizations can be
036managed that way. We meet with the lead, or I meet, there's me, the we, the we, me and the mouse in my pocket, meet monthly to go over capital projects and what is prioritized. And so the management, along with what the foundation believes that we can fund, meet together to talk about what the priority is. Yeah, I think the point is, yeah, I think the point is, The foundation is not being asked to fund a project that management hasn't brought forward. Asked them to do. Well, no, no, as a capital item. So I don't think there is the dynamic of we don't want to pay for it, so you guys pay for it. It could happen. Based on what you just said. It could. It could happen. But I don't think that's the way it
037works. My experience with the folks here, coupled with in other settings, is... You know, there's enough dialogue that they're funding something that we think is really critical. Who's we? Pardon? Who's we? I'm sorry? Who's we? We? Yeah. You just said we. We, the management. Okay, I get the management part. I have no doubt about that. And they wouldn't do it if they weren't supportive of it. Yeah, I just don't think that is anywhere near a board approval issue. I guess my question is, if we have a project that was identified, we raise the money, it's paid for, we have the money to pay for it. They come to the board and management comes to the board and says, we want to buy this striker machine, we have the money for it, this is what the
038contract looks like, and that's for us to approve. See, but Ed just said no. They don't come to you. I think that's after the fact. Right. No, after the fact. But you said no fact at all. Well, it's part of the capital plan. Right. Okay. So the funding source is separate from the capital plan. Okay. I think we're collectively mixing metaphors because if they can go to a separate source other than... If management can go to a separate source, being the foundation, the question is whether the board should be notified at all. And what you just said is since they're going to a separate source, it doesn't need to be in the capital plan at all. No. I said it doesn't need to be approved by the board that we're asking the foundation for a
039million dollars. It should be. I mean, the capital plan has to include anything that was put into us. I agree with that. And we do approve the capital plan. And this item was included in, I mean, if you remember back to our budget this year, we condensed our capital needs just to be, you know, here are the critical capital priorities I know we're going to need to address in this fiscal year. I mean, I think there was dialogue at that point then about how the foundation could assist. I think... Policy-wise, management could not move forward with any capital project, even if it was funded by the foundation, if it was not on our capital plan or approved by the finance committee and board. I think the only difference is, and I see your point, Ed,
040that if the capital plan is approved before they start that dialogue, then we're approving it before. I don't think we should be approving it afterwards. they should not be meeting with the foundation to discuss a project that we haven't had in the capital plan. We're just not, my feeling is as a board, we don't have to specifically say it's okay for you to get a million dollars for a striker. Yeah, again, I'm not concerned how they fund it unless we're funding it as long as there was approval somehow. Right. Any other questions? You didn't answer that question. I did not. Anything else? We thank the foundation and we thank you. We couldn't do many of these capital projects without you. And it was a great physical therapy grand opening. It was. Thank you. Thank you
041for attending. Yeah. If you haven't seen the space, it's amazing. It's beautiful. It's really beautiful. Okay, thank you. Thank you All right. Next up. We have a resolution To oh you're presenting. No, you're presenting. Yeah Same resolution different same resolution as last month different names. Yep, correct. So this resolution just formalizes Kelly as the CEO and then in addition includes me as a authorized signer for Banking matters as a CFO in addition to Wendy and Kelly So any questions at all on the resolution As long as I hear everyone's individual ayes. Aye. Thank you. Next item, I believe it's the line of credit, or is it the audit? It is. The audit results. The audit. So... Baker Tilly, formerly Moss Adams, they just completed our second year of assurance of services for the district. They
042presented the audit report to our finance committee last week, which we, since this year, merged both the finance and audit committee into one committee. They started the audit. They came out, I think, in the beginning. Actually, I think they were actually out in July to start field work. They were out here two to three weeks in August. We got the report a couple weeks ago. Happy to report no significant findings, no misstatements. Pretty clean audit, which I am very pleased to report. Not sure if you guys had a chance to read the 100-page audit report and stay awake while reading it, and if you did, kudos to you. I do want to just make a quick note. We are making just a couple few changes, just some back table disclosure notes in the report, but
043nothing at all that changes any numbers or anything like that. So I am here to answer any questions you all may have, but we need an action on approval of the fiscal year 2025 budget for the health district. Or audit, excuse me. Sorry. Yes. I would just make a couple comments. First of all, it's great to have an unqualified opinion. We did this, Ben did this, you know, while he was acting as interim CEO. He and Lois did a fabulous job. I spoke with the auditors. They were very much on board praising the activities throughout the year because the audit looks at the end result. They also go back and look at stuff going on during the year. And all that was done in a very professional way. And kudos to Ben. And kudos to
044Get the Audit Report. I hate to say I'm old enough to say 50 years ago I started doing audits. And they were about 15 pages. today it was 70 yeah I mean it's ridiculous what you have to do nowadays but they got it without issue so I recommend we approve the audit all in favor aye any opposed echo its comments to both Ben and Lois and Ben since he was doing double duty at the time and we got done on time when we wanted it with a phenomenal result. So congratulations. Well, thank you very much. And I just want to make sure that I highlight Lois Ruszynski. I mean, she was, she drove this thing and she came on last November. And I wish we had found her sooner. And our audit has just, just
045the timeline and everything has just been, it's been nine days since she's been here. So I want to make sure that I call her out. Seems like we've gotten into a nice rhythm, too, with Moss Adams. Is this their second or third? This is their second, yeah. And I think so. And I think they have a lot of district hospitals as their clients, which I think helps. I do think a couple years ago there were some new GASB accounting standards that kind of tripped us up a little bit. With it being a first year of Epic, you know, just going through the contractual reserves just took a little bit longer. But I agree. I mean, just the response time, everything has been, we are very, very pleased with, and we view them as a great
046partner going through the process. Just a quick point of clarification. They've mentioned a couple times that their official name is Baker Tilly now. So we're going to move into the line of credit? Yes. So this is something that we have been discussing. have given updates on this here at the board we've discussed this in quite a bit of detail in our Finance Committee meetings over the last you know three four months if you guys all remember we migrated to Summit Bank about a year ago and part of that process was they refinance and took on an existing legacy line of credit and then in addition to that offered us an incremental additional line of credit that allowed us to be able to kind of backfill operating cash and just tap into some of the additional
047supplemental funding that we've been able to negotiate. So this line of credit is this renewal increases our available line of credit from five and a half million to 10 and a half million. There were a couple other Very minor changes just in terms of just some of the fees which I did list in the memo But that really for the most part is is pretty much it in terms of just the things that have changed This we actually do have the ability to renew this five more times after this room after this iteration, so We will have some length to this And then I think going forward, you know, I think there's some opportunities just to carve out maybe some additional flexibility for the district within this agreement. But for the time being, this certainly
048fits our needs in what we're looking to do financially this fiscal year. So this was presented last week at the finance committee, was recommended for approval for the board. And I will just stop and answer any questions you guys may have. I WOULD SECOND THAT MOTION SUBJECT TO WE STILL NEED TO CHANGE THE SIGNATURE YES WHICH THEY UM WE NEED A SIGNED RESOLUTION UH TO DO THAT SO UM WHICH WE WILL HAVE AFTER TODAY SO BEN OKAY ONCE WE WE JUST NEED TO GET BACK YES WE'VE DONE THE RESOLUTION WE APPROVE THIS WILL THEY SEND WILL THEY SEND UM More emails. Yes Yes, yeah, yeah because if they do if we are changing then yeah, we'll have to get them to modify that but Yes, so I will have them pull that and then I
049will let you guys know when yeah, yeah, yeah happy to do that No, exactly As a point of clarification, did we say aye to that? We did not. Okay. I seconded, so. All in favor? Aye. Any opposed? Okay, separate issue. Just as a point of clarification, one, great job. As Ben knows, this was an item that I was very anxious about since once we make the payment and once we get the money from the state. It helps us from a financial standpoint significantly. So kudos to Ben with the variety of different options that he was able to present. It's worthy to recognize, and it's on Ed's agenda, is even though they've said that they're willing to consider renewing this five more times, they do have an annual right to say no. So I think our
050next step is trying to find something for the hospital that gives us more length, more tail, that we're not having to address this. Yeah, I think that's a good point. I mean, we're blessed to have a finance committee that has a number of people with good experience in the financial world, Dennis and Paul. What I've asked is that we put together a little group to begin to evaluate other financing options. because while this is a $10.5 million financing opportunity for us, it also has a 150-day repayment requirement. So it's really only available. Its primary and almost exclusive function is to get us through the IGT. So we get this money. and we get the IGT and then we use that to pay it back. It's not a true line of credit where you could draw
051upon it and assume you may have a year or two to pay it back. So we're going to look at trying to get ourselves better positioned with some alternative means of financing, maybe keep this as IGT only. I don't know the answer to that, but we've got some time now. A separate issue. Who knows if IGT is going to be around next year and the year after, but if we continue to go at this pace, you know, possibly next year it's going to be much larger, and we don't know collectively if Summit can actually address a larger request. And Ben's got potentially other alternatives as well. So I agree with you, Ed. It's something that we have to look at. and the IGT payment makes us healthier for some financial institution to consider us. So
052great job, Ben. Thank you. Thank you. We have Dr. Okolo who's going to do a CMO update. His first. Welcome. Good evening. Good evening. I will launch into it because the night is already mature. And I'll do the opposite of our foundation presentation and just only use my first slide. Because I think the first slide really, Whitney, if you get it up for me, really tells the story of what happened as I've arrived in Sonoma and looking backwards. And it's always good to listen to stories and understand where you are. And so sort of looking at our volumes, using the emergency department as the template for what happened. This hospital was healthy and did quite well in 17 and 18. And then came that pandemic that we remember. member. And that pandemic really plummeted the
053numbers of people coming through the door. And in so doing, there were many moves in parallel in the same direction as the patient volumes coming through the door. Since that pandemic was over in 22, 23, and most robustly in 24, those volumes have exceeded what they were back in 17 and 18. And on pace this year, if we annualize the number of visits coming through the Sonoma Valley Hospital ER, we expect to do better than all of those years looking backwards. In parallel with that, the number of admissions to the hospital has remained stable, vacillating between 7 to 8 percent, and the number of transfers out have been between 5 and 6 percent, demonstrating great operational elasticity. The way that things have been done at Sonoma Valley prior to my arrival was using a very
054lean strategy to do things. and within that lean strategy, just do it approach to certain things. So many people are wearing different hats and juggling and doing lots of things, which is really fiscally conservative and fiscally efficient. But that really exposes us to what I think is one of our weaknesses, which is the absence of redundancy. And we understand that this absence of redundancy It helps to keep the balance sheet where it is, but really impedes our ability to grow. So to echo what he was talking about earlier, I personally responded to an ad for a foundation job here in Sonoma, but it was meant to be. I got here and there was no foundation, but I still stayed. But I think it would be wonderful in terms of the opportunities that we have. to
055really focus on broadening our primary care base. And from that primary care base and broadening that primary care base, bringing internists, family practitioners, gynecologists into the valley, it is from there that our specialists will grow and the specialist cater will grow. Immediately we have opportunities to start with gastroenterology because I'm a gastroenterologist and I think there are nephrologists who also want to come into the valley. We want to multiply this and multiply this and do this over and over again for the hospital because it is through that volume that would allow us to have that base that then allows us to have more operational efficiency. much more redundancy in terms of staff, in terms of reducing turnover, in terms of improving the connectiveness within our ecosystem. I think one of the biggest challenges or bigger
056challenges that we have is really connecting all of that internal as well as our external ecosystem. Our major external ecosystem is with UCSF. We need to be able to communicate with UCSF. And in being able to communicate with UCSF, we need to speak the same language as opposed to remaining in a polyglot environment as we are. And that takes some thinking and some courage on our part so that we're on the same interoperable platform. There was a question earlier about how this works. And even though we can market to people about coming to the Valley for their care, It's the mechanics of sending people. So if I as a doctor seen somebody can have a single click and send someone to a valley practitioner as opposed to faxes multiple phone calls, etc this is the
057kind of milieu that really doesn't allow that kind of connective tissue. So we're looking for courage as we go in terms of the opportunities that we have to really strengthen this connective tissue that we have for our community here, in terms of our clinics, in terms of the people who practice around, and externally with UCSF. I think to your question, Wendy earlier, I'd be very eager to work with Ted Abraham and Josh Adler and Luke Dajon to see about bringing people into this community. This is not a hard sell. This is not moving to other parts of the country where the community is a hard sell. This is a very easy sell. It is those details that Dr. Amara was talking about that we need to pay attention to. And with doing that, I think
058we can really have three robust lines of taking care of people in terms of a strong primary care base, an adequate specialist base, and a boutique base of medicine to practice. Our threats are things that we cannot really control. He articulated many of those threats, and I won't echo all of those. But I think for us, as a community and for the border our biggest threat is just not having enough courage to move forward so that we stop blocking and tackling and actually grow as as a community and as a district hospital which i think is quite possible thank you i'll take any questions you know you you reminded me of a conversation i think i had i know i had with john henley me i'm looking at ben maybe he'll remember Am I remember
059correctly that at one point there was we were going to pursue a strategy to leverage UCSF's foundation in the East Bay I remember it I think we were primary care Am I remembering this correctly? You very well could be I I remember we were looking to We're working with UCSF to see, in this particular instance, to recruit a GI position that we were going to recruit through, I think, their Children's Foundation. There certainly could have been an additional discussion revolving primary care as well. Yes, that actually made it mature, you know, went all the way to a national, which I saw on the other side of the country. And that's how I'm in Sonoma today. So you're quite, quite, quite right about that. But maybe that's something you can talk to Dr. Abraham about. I
060just remember, it's like way back here, talking to John about it. Am I remembering correctly? Certainly things for us to pursue to really mature that. Similar to our radiologists and some of the other practices that I guess are in the foundation that we've contracted groups to support the hospital. Are there any family practice groups that we could contract to support Sonoma and Sonoma Valley? I think we have to look into that. It's clearly where the future is pointing towards, attracting people and using the, you know, the largesse of the foundation and all our resources to bring people. Because what I'm thinking is there are communities like Oakland, Berkeley, or Rinda that many doctors from there may actually have second homes here that... if they're willing to do dual coverage. Anyways, that maybe we can get
061a practice that's willing to support Sonoma if Sonoma itself can't seem to homegrown those areas of physicians. Yes, no, I think you're spot on. Thank you. Thanks very much, indeed. Thank you. All right. We have Ben up for the CEO report. and the financials. Yes. So I will, if okay, I'll kind of try to somewhat combine both since there's some financial stuff within the CEO report. But yeah, first and foremost, certainly we are more than thrilled to welcome Kelly here. And so we, I think we've been very... I don't know how you put this. Very intentional about trying not to get every, everybody wants a piece of her right now. So we're, you know, and we need her. So, but we are working through that and just very excited that she's here and a little
062more pep in the step, I think this week. So a couple updates. We did receive our final estimate for this year's rate range IGT program. We will be netting about $12 million this year, which is about a $5 million increase over last year and actually $9 million more than we received two years ago. So obviously that's a huge thing for us. IT REALLY RAISES OUR FLOOR, I THINK, FROM A CASH PERSPECTIVE. OUR MATCHING FEE PAY-IN WILL BE DUE NOVEMBER 20th. SO WE'VE GOT ENOUGH TIME TO WORK THROUGH ALL THAT STUFF, BUT GREAT TO BRING THIS STUFF TO COMPLETION AND REALIZE THAT. SO I'M SUPER PLEASED ABOUT THAT. A COUPLE UPDATES ON PROJECTS. WE ARE STILL WORKING WITH THE CITY ON SOME ITEMS. related to that are needed to complete in order to still obtain permanent
063occupancy in the MRI trailer. There are a couple sound studies I think that we're working with the city on so work continues there. I think I did report last month the ICU refresh project is fully done so great to get that off our plate and then happy to report that I think it was a Monday. or Tuesday we received full permanent occupancy for our PT space so we are we are good to go there and so I did want to just highlight and call out you know Dawn Kuwahara, Chris Gallo and Kimberly Drummond who have been instrumental in just making sure that that was progressing as fast as it could and really working with HCHI and really putting their holding their feet to the fire to get this thing open But we are very excited
064about that so happy to report about that I did mention the CEO report. We're still working through just how to fund some capital needs very thankful for the foundation and their willingness to help raise for the Stryker OR replacement. But we're working through some other things. There are a couple other equipment needs as well as some building infrastructure needs that we're going to have to figure out a funding source for. So just wanted to call those out as well. And then just on the financials, I will say it's just another positive month. September, we posted an operating EBDA about $360,000. Through the first quarter of this fiscal year, our operating EBITDA is close to a million and a half. And our operating margin, we've got an operating loss of just over 100,000 through this first
065quarter. So I just said, I mean, we're getting much closer to an operational break even. You know, I think we've kind of spoke on that over these, you know. this last year and looking purely at operating EBDA and kind of excluding depreciation. Well, actually now including depreciation, we actually had a positive operating margin in August. And again, you know, we're getting much closer. The 100K loss through the first quarter compares to, you know, we budgeted to have an operating loss of a million dollars through this first quarter of this fiscal year. So certainly a lot of improvement there. I will say, you know, if you remember back to budget, we budgeted about $10 million for net benefit for this rate range IGT program. So there's still, once that gets fully closed and we get our
066payment in, and we accrue what we budget equally each month, and then we will true that up once we get our payment. So from January through the end of this fiscal year, we'll be accruing about $2 million more through that program. So there's further upside there. And then I think, you know, just in September, from a volume perspective, it's just kind of more of the same. I mean, emergency room continues to be very busy. We average 32 and a half visits per day in September. Our volumes are up 10% versus budget and prior year, year to date. Our surgical volumes in October were 15% over budget. And happy to report we actually set another all-time high in MRI exams in September as we... reached 250 for the first time. So, and that exceeded an all-time
067high that we set, I believe it was in July. So great to see the positive momentum there. We are starting to see more UCSF referrals, excuse me, come in. So that's great. And then we actually are moving on setting up a work group with UCSF and Dr. Abraham to kind of really start attacking that a little bit with a little more fervor. So, So further opportunity there. You know, all in all, I mean, obviously, yes, a lot of shakeup and potential concern, and there's a lot still that we need to do. But I think, you know, financially, compared again, especially where we were a year ago, very pleased with the progress. So I will stop there, and I'm happy to answer any questions you guys may have. Ben, when does the IGT payment come in?
068January. January. Yeah. I THINK IT CAN BE SOMEWHAT NEBULOUS IN WHEN. THE PAYMENTS WILL COME INTO THE HEALTH PLAN AND THEY THINK THEY DO HAVE UP TO 30 DAYS TO DISTRIBUTE. PARTNERSHIP HEALTH PLAN IS VERY GOOD THOUGH ABOUT TURNING THAT AROUND. WE USUALLY GET THAT PAYMENT WITHIN A COUPLE DAYS. AND I BELIEVE WE GOT IT WITHIN 24 HOURS LAST YEAR. THAT DID INVOLVE LOIS DRIVING TO SACRAMENTO, OR FAIRFIELD, BUT YEAH, WE GOT IT. YEAH. Yeah, I you know as much as I wanted ten million dollar checks, you know coming through the mail. Yeah. Well, yeah, how long has our Striker robot how long have we been using it? I believe over ten years. No, no, I'm sorry a new one the one we oh the Rosa the Rosa. Sorry. Yes the Rosa just Just under
069a year. Yeah under a year. Okay, and where are we on the Under over under in terms of our commitment to get it free. Yes, I can I can certainly put numbers again to do a report out we are We are not quite meeting the threshold there. You know when you add in You know some of the other savings that we had in relation to some of the implant costs That we received because we were able to get into more preferred preferable contract. I do think we are still Coming out as a cost savings I think we did budget to not quite hit the threshold this year, but yeah, we are not quite there this year. And blanking on the doctor's name, that was one that primarily was Dr. Walter? Oh, okay. Are others using
070it? There is another orthopod that is trained on it, and I think he has used it, but Dr. Walter is primarily the... surgeon that uses it the most. And are, yes. Yep. And are, is Dr. Walter using it on every surgery? On the, um, on his joint, um, on his joint cases? Yes. Yep. Whenever he can. Okay. You're between us and the adjournment. We have a committee update. It's just the work plan and we've kept it pretty similar to the last year. We have all the departments represented for presentations. We're sticking with the 10 meetings as per our charter. We have switched to, instead of the fourth Wednesday, to the last Wednesday. So I hope that doesn't confuse too many people, because we do have 50, 60 people that come to these meetings. Not. No,
071we have a wonderful group. The Quality Committee is doing a great job, and we got this off our plate now before all the other committees' work plans. I'm going to do what Susan Nydell used to do. This is my first year on this committee. It really is a good committee. I mean, I learn a lot. Everybody's engaged. We have some great volunteers who have been on the committee for years. Up to 10 years. I learn a lot. It's a good committee. So we need to actually approve this, right? Oh, we have a motion to approve? Second. All in favor? Aye. Any opposed? All right. Any comments from the board? No. If not, meeting adjourned.