At the October 23 Greenwood County Hospital Board of Trustees meeting, Quality/Risk Manager Melissa Jones presented the Quality Assessment Performance Improvement (QAPI) plan, for approval.
Jones explained that the quality plan details the obligations of all hospital departments, each of which, she said, is responsible for making and reporting quality improvements. Among the QAPI plan’s new initiatives for GWCH are goals to adhere to the American Heart Association’s acute stroke measures; one specific measure is to make sure that a CT (computed tomography) scan is performed within 25 minutes of a stroke patient’s arrival at the hospital. A continuing goal, Jones said, is to maintain the hospital’s level IV trauma designation. A Level IV trauma center provides initial care, stabilization, and advanced trauma life support (ATLS) before transferring patients to a higher-level trauma center. Home Health participated in the hospital quality initiatives but, Jones explained, they also have their own plan as well. The Home Health quality plan, including targets for improvement, was included in the vote for the QAPI plan, which the board approved as presented.
Jones also presented an update on quality metrics for 2025, noting an improvement to 78% in the hospital’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score, a patient satisfaction survey. GWCH is on target for several goals, including sepsis bundle compliance, which refers to the adherence to a set of interventions aimed at improving the early management of sepsis and other severe infections. Jones shared that the hospital had met the Blue Cross and Blue Shield (BCBS) benchmark of 80% for hand hygiene with an overall score of 91%. By meeting that and other BCBS benchmarks, GWCH is eligible for reimbursement. Jones noted that GWCH has a target goal of 93% for this important safety measure. Jones also gave an update regarding the Patient and Family Advisory Council (PFAC) which, she explained, is a group of current or former patients, families, and hospital staff who work to improve the quality and experience of care. They provide feedback on hospital policies, programs, and services, acting as a direct link between the community and the hospital. Jones said the hospital is in the process of recruiting advisors. Those interested should reach out to Jones at GWCH.
CEO Report
In her CEO report, Sandra Dickerson told the board that an in-person meeting was held with CI. Health Group, the recruiting firm, regarding obtaining a new physician for the Eureka Clinic. GWCH provided specific criteria needed for the position, and CI presented questions potential physicians might ask regarding the clinic, the practice, and the community. Dr. Basham, APRN Jennifer Eagleson, and several other staff were present to provide input. The next step, said Dickerson, is that CI will develop a marketing plan to get recruitment underway.
Dickerson shared that GWCH’s newly hired Marketing/ Foundation Director Rachel Sample, RN, is set to begin work on Nov. 3. Sample’s duties will include visiting physician clinics outside of Greenwood County to talk to them about the services provided by GWCH. Because she has a medical background, Sample will be better able to answer any questions those facilities might have, said Dickerson.
New Chief Financial Officer James “Butch” Forrest is set to begin work at GWCH on Dec. 1. Forrest has over 20 years of experience in healthcare finance and has worked in Critical Access Hospitals (CAH) in Texas, Colorado, and Kansas. Current CFO Melody York will continue during Forrest’s transition into the role.
Lastly, Dickerson told the board that the state is putting the finishing touches on the application to CMS (Centers for Medicare & Medicaid Services) for funding available through the Rural Health Transformation Fund (RHT) and the One Big Beautiful Bill. The RHT is a federal funding initiative meant to support rural health care. Dickerson said that she is not optimistic about GWCH’s ability to receive much in the way of funding through the program. Hospitals must adhere to strict guidelines to gain funds. The process, said Dickerson, is not unlike granting. GWCH would need to submit a plan to CMS, who would then decide if the proposal fit within their own plan before granting the money. The guidelines, said Dickerson, are very specific, and several things, such as new buildings and provider salaries, are excluded, making it difficult to find projects that fit within the criteria allowable by the fund. The final plan is due to CMS on Nov. 5, and approval or denial is expected to be published by Dec. 31.
No financial report was given during the Oct. 23 meeting. CFO York explained that there were some issues with their software which went back a few months. Rather than present an inaccurate report, York said, GWCH will be working with Great Plains Health Alliance to get the software issues resolved before presenting the financial reports.
Medical staff met on Tuesday, Oct. 21; Dr. Mike McClintick presented some education and the med staff were presented with some process improvement ideas on tracking lab cultures as well as new trauma policies aimed at achieving the trauma designation by the end of the year, if possible. No appointments or reappointments were presented for October.
The board approved the consent agenda as presented, including minutes of the Sept. 25 board of trustees meeting, the September treasurer’s report, and September disbursements; payroll and benefits totaling $987,469.20; and accounts payable totaling $624,773.94.
Due to the Thanksgiving holiday, the GWCH Board of Trustees voted to move the November meeting date to Tuesday, Nov. 25. The meeting is set for 5:30 p.m. in the conference room of GWCH.
