quality, safety & education and full board of directors ...of directors meetings thursday,...

Lee Memorial Health System Board of Directors

Quality, Safety & Education and Full Board

of Directors Meetings

Thursday, October 26, 2017 1:00 p.m.


BOARD OF DIRECTORS OFFICE

239-343-1500 FAX: 239-343-1599

13685 DOCTORS WAY #190 FT MYERS, FLORIDA 33912

CAPE CORAL HOSPITAL

GULF COAST MEDICAL CENTER

HEALTHPARK MEDICAL CENTER

LEE MEMORIAL HOSPITAL

GOLISANO CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA

THE REHABILITATION HOSPITAL

LEE PHYSICIAN GROUP

LEE CONVENIENT CARE

BOARD OF DIRECTORS

DISTRICT ONE

Stephen R. Brown, M.D.

Therese Everly, BS, RRT

DISTRICT TWO

Donna Clarke

Nancy M. McGovern, RN, MSM

DISTRICT THREE

Sanford N. Cohen, M.D.

David Collins

DISTRICT FOUR

Diane Champion

Chris Hansen

DISTRICT FIVE

Jessica Carter Peer

Stephanie Meyer, BSN, RN

AGENDA

QUALITY, SAFETY & EDUCATION AND FULL BOARD OF DIRECTORS MEETINGS

October 26, 2017 at 1:00 p.m.

Gulf Coast Medical Center – Boardroom (Medical Office Building) 13685 Doctors Way, Ft. Myers, FL 33912

1. CALL TO ORDER (Sanford Cohen, M.D., Board Chairman) Lee Memorial Health System Board of Directors, sitting as the Board of Directors for Lee Health, Gulf Coast Medical Center & Lee Memorial Hospital/HealthPark Medical Center and the Board of Directors of its subsidiary corporations, including but not limited to Cape Memorial Hospital, Inc. doing business as Cape Coral Hospital; Lee Memorial Home Health, Inc.; and HealthPark Care Center, Inc.

2. INVOCATION & PLEDGE OF ALLEGIANCE (Rev. Cynthia Brasher, MDiv, BCC)

3. PUBLIC INPUT – Agenda Items: Any Public Input is limited to three minutes and a “Request to Address the Board of Directors” card must be completed and submitted to the Board Staff prior to meeting. Individuals wishing to address the Board on a Non Agenda item must notify the Board Staff of the subject matter at least three (3) days prior to the meeting.

4. PRESIDENT’S REPORT (Larry Antonucci, MD, President & CEO)

Quality & Safety Portion: Steve Brown M.D., Quality & Safety Liaison

5. SAFETY STORY (Steve Brown M.D., Quality & Safety Liaison, Board Member)

6. CMS 5 STAR UDPATE (Marilyn Kole, VP Clinical Transformation) (Marcelo Zottolo, System Director Process Analytics) 1. Clinical Collaboration Council Update 2. PSI-90 3. Hospital Acquired Conditions 4. Documentation CCG

7. INTEGRATING QUALITY & SAFETY PERFORMANCE IMPROVEMENT (Chris Crawford, VP Standards and Quality)

8. SAFETY ACTION PLAN & SAFETY CULTURE UPDATE (Alex Daneshmand, D.O., Patient Safety Officer)

9. PATIENT EXPERIENCE – OUTPATIENT SURGERY CENTER (Kathy Fairfax, RN, MHA, CNOR, Acting Director, Surgery Center, Sanctuary

10. SYSTEM PERFORMANCE INDICATORS (Accept) (Marcelo Zottolo, System Director Process Analytics)

11.

ANNUAL ETHICS REPORT (Accept) (Rev Cynthia Brasher, MDiv, BCC)

LEE HEALTH BUSINESS – Sanford Cohen, M.D., BOARD CHAIRMAN


BOARD OF DIRECTORS

OFFICE 239-343-1500

FAX: 239-343-1599

13685 DOCTORS WAY #190 FT MYERS, FLORIDA 33912

CAPE CORAL HOSPITAL

GULF COAST MEDICAL CENTER

HEALTHPARK MEDICAL CENTER

LEE MEMORIAL HOSPITAL GOLISANO CHILDRENS HOSPITAL

OF SOUTHWEST FLORIDA

THE REHABILITATION HOSPITAL

LEE PHYSICIAN GROUP

LEE CONVENIENT CARE

BOARD OF DIRECTORS

DISTRICT ONE

Stephen R. Brown, M.D.

Therese Everly, BS, RRT

DISTRICT TWO

Donna Clarke

Nancy M. McGovern, RN, MSM

DISTRICT THREE

Sanford N. Cohen, M.D.

David Collins

DISTRICT FOUR

Diane Champion

Chris Hansen

DISTRICT FIVE

Jessica Carter Peer

Stephanie Meyer, BSN, RN

AGENDA (Page 2 of 2)

QUALITY, SAFETY & EDUCATION AND FULL

BOARD OF DIRECTORS MEETINGS October 26, 2017 at 1:00 p.m.

12. PLANNING & FULL BOARD MEETING MINUTES OF 10/12/17 (Approve)

13. RISK MANAGEMENT REPORT (Accept) (Mary Lorah, Risk Manager II)

14. MEDICAL STAFF RECOMMENDATIONS (Approve) 1. Lee Memorial Hospital 2. Cape Coral Hospital 3. Gulf Coast Medical Center 4. HealthPark Medical Center 5. Golisano Children’s Hospital of SWFL

15. OLD BUSINESS

16. NEW BUSINESS

17. BOARD MEETING CRITIQUE

18. BOARD OF DIRECTORS REPORTS

Date of the next Meeting:

November 9, 2017 at 1:00 p.m. Finance Board and Full Board of Directors Gulf Coast Medical Center – Boardroom

13685 Doctors Way, Ft. Myers, FL 33912

19. ADJOURN (Sanford Cohen, M.D., Board Chairman)


BOARD OF DIRECTORS

Invocation &

Pledge of Allegiance


BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS

PUBLIC INPUT – AGENDA ITEMS:

Any public input

pertaining to items on the Agenda is limited to three minutes and a

“Request to Address the Board of Directors” card must be completed

and submitted to the Board Staff

prior to meeting.

Refer to Board Policy: 10:15G: Public Addressing the Board Non-Agenda Item: Individuals wishing to address the Board on an item NOT on the Agenda, the Board office must be notified of subject matter at least three (3) days prior to the meeting to allow staff time to prepare and to insure the matter is within the jurisdiction of the Board.


BOARD OF DIRECTORS

PRESIDENT’S REPORT

Larry Antonucci, MD, CEO & President

Lee Health

Board of Directors Meeting

October 26, 2017

President’s Report

Doc Coggins Reflections

FHA Annual Meeting

DC Highlights

Behavioral Health Summit

Strategic Plan Update

Operational Plan Guiding Principles

Cost Reduction Imperatives

BOARD CHAIRMAN TO Quality, Safety & Education LIAISON:

Quality, Safety & Education: BOARD OF DIRECTORS

MEETING

Thursday, October 26, 2017 1:00 p.m.

QUALITY, SAFETY &

EDUCATION LIAISON: Steve Brown


BOARD OF DIRECTORS

SAFETY STORY (Steve Brown, M.D., Quality & Safety Liaison, Board Member)

BOARD OF DIRECTORS

CMS 5 STAR UPDATE (Marilyn Kole, VP Clinical Transformation)

(Marcelo Zottolo, System Director Process Analytics)

1. CLINICAL COLLABORATION COUNCIL

UPDATE

2. PSI-90

3. Hospital Acquired Conditions

4. Documentation CCG


BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS

INFORMATIONAL REPORT TO THE BOARD (No Action Required)

Keep form to one page, EMAIL to [email protected] by Noon

Eight (8) days PRIOR to presenting

DATE: 10/26/2017 NAME OF SERVICE LINE/ENTITY UPDATE: CMS 5 Star Update PERSON RESPONSIBLE & TITLE: Scott Nygaard, MD, Chief Medical and Clinical Integration Officer, KEY ACCOMPLISHMENTS

• Lee Health’s group scores continue to improve (remaining at 2 stars) • CCH improved to statistically better than national average in Safety domain. • HAC performance improving; 2 campuses (CCH, GCMC) penalty free for FY18 • Clinical Consensus Workgroups launched for development of evidenced based guidelines to

decrease HAI’s

GOALS (MET) N/A

GOALS (UNMET) N/A

FINANCIAL IMPLICATINS (if any) N/A PROBLEMS/ISSUES

1. Evidenced based Guidelines for Central line bloodstream infections and catheter associated urinary tract infections will be completed this month but require testing and Medical staff approval before Go live

2. Group scores continue to lag behind national averages. National thresholds are improving.

ANTICIPATED NEEDS N/A SUMMARY/COMMENTS Update of organizational performance on CMS 5 Star measures reported in October 2017 Hospital Compare publication. Clinically integrate Safety and Quality at Lee Health Safety Program-Building safety action plan together This UPDATE supports the following Strategic Initiative(s): _____________________________

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CMS 5 Star Dashboard Update

Scott Nygaard, M.D., M.B.A., Chief Medical & Clinical Integration Officer

Marilyn Kole, M.D., M.B.A., Vice President, Clinical Transformation

Alex Daneshmand, D.O., M.B.A., Patient Safety Officer/Acute Care Medical Officer – Golisano Children’s Hospital

Marcelo Zottolo, MS, System Director, Process Analytics

October 26, 2017

Quality, Safety & Education Board of Directors Meeting

•The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations.

Clinical Collaboration Council“Evidenced based practice model for Lee Health”

Active Clinical Consensus Workgroups

Current Progress: System Program Management Process

1

Medical Staff Governance/Quality

CMS STAR UPDATE

5

CMS 5 Star Ratings Program Recap

6

Measures Weighting

Safety of Care 22%

Patient

Experience22%

Readmissions 22%

Mortality 22%

Effectiveness 4%

Timeliness 4%

Utilization of

Imaging4%

Some metrics are weighted more heavily than others

Areas where we currently perform well

These metrics have lower weights

• Lee Health’s group scores continue to improve but lag behind national averages

• CCH improved to statistically better than national average in Safetydomain.

CMS Overall Hospital Quality 5‐Star RatingBased on Hospital Compare October '17 Preview

Measure Group Performance Period WeightCCH Group

Score

GCMC Group

Score

LMH/HPMC

Group Score

National

Group Score

Number of

Measures

(1) Outcomes: Mortality Q3CY13‐Q2CY16 22% 0.46 0.40 ‐0.22 0.00 6

(2) Outcomes: Readmission Q3CY13‐Q2CY16 22% ‐1.26 ‐0.70 ‐0.85 ‐0.03 7

(3) Outcomes: Safety Q1CY16‐Q4CY16 22% 0.45 ‐0.38 ‐1.22 ‐0.01 7

(4) Patient Experience Q1CY16‐Q4CY16 22% ‐1.68 ‐1.03 ‐0.59 0.00 11

(5) Process: Effectiveness Q1CY16‐Q4CY16 4% 0.33 ‐0.31 0.09 0.00 10

(6) Process: Timeliness Q1CY16‐Q4CY16 4% ‐0.63 ‐1.60 ‐0.94 0.03 6

(7) Efficiency: Imaging Q3CY15‐Q2CY16 4% ‐0.51 0.22 ‐1.71 0.01 4

Overall Summary Score 100% ‐0.48 ‐0.44 ‐0.73 N/A 51

Overall Star Rating 100% 2 Star 2 Star 2 Star

Notes:

Numeric scores represent the number of standard deviations above or below the National mean. Higher is betterAbove National Avg (4 Star)

SameNational Avg (3 star)

Below National Avg (1‐2 Star)

Above National Avg (5 star)

‐0.83 ‐0.86 ‐0.87 ‐0.87

‐0.78

‐0.48

‐0.84

‐0.93‐0.88 ‐0.88

‐0.66

‐0.44

‐1.02‐0.97

‐0.93 ‐0.93‐0.87

‐0.73

‐1.25

‐1

‐0.75

‐0.5

‐0.25

0

0.25

0.5

Jul '16 Oct '16 Dec '16 Apr '17 Jul '17 Oct '17

Standard Deviations from National Avg

CMS5StarSummaryScorebyPublication

CCH GCMC LMHHP

2 Star threshold (‐0.96) 3 Star Threshold (‐0.33) 4 Star Threshold (0.25)

4Stars

3Stars

2Stars

1Star

CMS 5 Star Campus Overall Star Rating Trend

• All campuses continue to improve summary score. CCH and GCMC trending towards 3 Star Overall. Note that performance is being compared to May 2016 Benchmark. CMS is in the process of updating national thresholds.

• Not every measure is updated on every publication. Some measures, like mortality and readmissions are updated on an annual basis (in July)

• Note that July ‘17 Summary Scores are unofficial and were not published due to errors in CLABSI,(Central line bloodstream infections), & PSI90, (Patient Safety Indicators) calculations.

Data Source: CMS Hospital Compare October 17 Preview

• Most improvement occurred on Imaging, Safety and Readmissions

• CCH improved to statistically better than national average in Safety domain.

• This helps us to change our approach to prioritize our improvement efforts

‐3.0

‐2.0

‐1.0

0.0

1.0

2.0

3.0Mortality Readmission Safety of Care Patient Experience

Efficient Use ofMedical Imaging Timeliness of Care

Effectiveness ofCare

LH Overall Star Rating Group Scores By Campus

CCH LMH/HP GCMC

National Average

Better than national average

Worse than national average

Most measure groups improved but lag behind national averages

11

Clostridium difficile(C diff)

Clostridium Difficile WorkgroupStuart Paasche, P.A., Co‐ChairHolly Muller, RN, VP, PCS Co‐ Chair

12

Describe improvement or changes made since last meeting

• Improve early identification of Community onset Clostridium difficile patients on admission• Education to re‐introduce Clostridium difficile as a clinical diagnosis not a lab diagnosis• Identified key risk factors for Clostridium difficile infections:

• Antibiotic stewardship‐limiting inappropriate use of antibiotics• Improved environmental cleaning of room and facilities• Improving hand washing compliance with soap and water

• Evidenced based guidelines for Antibiotic stewardship near completion

Clostridium difficile

64% reduction

13

Catheter Associated Urinary Tract Infection(CAUTI)

Catheter Associated Urinary Tract Infection WorkgroupJean Hage, M.D., Co‐ChairArchana Mandala, MD Co‐Chair Wendy Piascik, RN, VP, PCS Co‐Chair

Safety Domain – Hospital‐Associated Infections

14

Catheter Associated Urinary Tract Infection

Describe improvement or changes made since last meeting

• Evidence based Guidelines for Insertion, Maintenance, and Removal of foley catheters‐Completion date: October 30, 2017

• Changing foley order to require order set completion to improve knowledge gaps • “Just do it” foley pilot ongoing in all Intensive Care Units‐ August 1st

Action Items

15

Central Line Associated Bloodstream Infection(CLABSI)

Central Line Associated Bloodstream Infection WorkgroupJordan Taillon, MD, Co‐ChairParmeet Saini, MD, Co‐ ChairCynthia Brown, RN, VP, PCS, Co‐ ChairSandra Simmons, RN,MSN, Director, ICU, HealthPark

Action Items

Central Line Bloodstream Infections

Describe improvement or changes made since last meeting:

• Evidence based Guidelines for Insertion, Maintenance, and Removal of catheters‐completion date: October 30, 2017

• “Just do it” pilot at HealthPark for standardization of indication for lines, pre‐insertion checklist, and Vascular Access Team intervention for line removal everyday

17

Surgical Site Infection(SSI)

Surgical Site Infection WorkgroupKiet Doan, D.O., Co‐Chair Jennifer Higgins, RN, VP, PCS, Co‐Chair

Action Items

Surgical Site Infections

Describe improvement or changes made since last meeting:

• Enhanced Recovery after surgery National Program: All Adult campuses• “Just do it” Standard data reporting to colorectal surgeons “pilot” ongoing at Gulf Coast• Surgical Site Infection Workgroup: initiated

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CMS Hospital Acquired Conditions Reduction Program Results


Safety Domain – Hospital-Associated Infections (HAIs) FY2018 HAC Reduction Program

Performance Period

FY2018 HAC Program used a performance period of CY15 and CY16Patient Safety Indicators:

.

Two of our hospitals have become penalty free this year (~$1.5M avoidance). This means we have outpaced the rate of improvement for the nation and moved out of the penalty zone (bottom 25th percentile).

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Leapfrog Preview Fall 2017


K. Alex Daneshmand, DO, Acute Care Medical Officer/Patient Safety Officer

What is Leapfrog’s Hospital Safety Grade?

22

Nonprofit organization committed to driving quality, safety, and transparency in the U.S. health system.

Publishes a safety letter grade and a numeric score twice a year Spring Publication (April)

Fall Publication (October)

50% Process Measures & 50% Outcome Measures. Data comes from CMS/NHSN

Annual Hospital Survey (same results used in the Oct and April publications)

Measure

Domain Measure

CPOE

ICU Physician Staffing

SP 1: Leadership Structure & Systems

SP 2: Culture Measurement

SP 4: Mitigation Risks & Hazards

SP 9: Nursing Workforce

SP 19: Hand Hygiene

H‐COMP‐1: Communication Nurses

H‐COMP‐2: Communiciation Doctor

H‐COMP‐3: Staff Responsiveness

H‐COMP‐5: Communication about Medicines

H‐COMP‐6: Discharge Information

Foreign Object Retained

Air Embolism

Falls and Trauma

CLABSI

CAUTI

SSI: Colon

MRSA

C. Diff

PSI 3: Pressure Ulcer Rate

PSI 4: Death Surgical IP Serious Treatable

Complications

PSI 6: Latrogenic Pneumothorax

PSI 11: Postoperative Respiratory Failure

PSI 12: PE/ DVT

PSI 14: Postoperative Wound Dehiscence

PSI 15: Accidental Puncture or Laceration

Process/Structural Measures (50%)

Outcome M

easures (50%)

SP = Safe Practices

23

Lee Health Spring 2017 Versus Fall 2017 Preview

*CMS made errors and did not pull recent data(impact)

*Survey questions will be answered going forward bySpecialized Team

24

Lee Health – Roadmap to “A”Recommended Metrics to Work on for Improvement:

Cape Coral Hospital1. H-COMP-2 Communication w/ doctors2. H-COMP-3 Staff Responsiveness3. PSI 12: Postoperative Pulmonary

Embolism (PE) or Deep Vein Thrombosis (DVT)

Gulf Coast Medical Center1. H-COMP-2 Communication w/ doctors

2. H-COMP-5 Communication about Medicines

3. H-COMP-1 Communication with Nurse

4. PSI 4: Death among Surgical Inpatients with Serious Treatable Complications

HealthPark Medical Center1. H-COMP-2 Communication w/ Doctors

2. PSI 6: Iatrogenic Pneumothorax

Lee Memorial Hospital1. H-COMP-2 Communication w/ Doctors

2. PSI 3: Pressure Ulcer Rate

3. PSI 4: Death among Surgical Inpatients with Serious Treatable Complications

System (annual survey sections)1. SP4: Identification and Mitigation of Risks and

Hazards

2. SP19: Hand Hygiene

3. SP3: Nursing Workforce

Our HAI performance in CY17 will impact our leapfrog scores next October

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CMS Mortality Performance

10/10/17


CMS Overall Hospital Quality 5‐Star RatingBased on Hospital Compare October '17 Preview

Measure Group Performance Period WeightCCH Group

Score

GCMC Group

Score

LMH/HPMC

Group Score

National

Group Score

Number of

Measures

(1) Outcomes: Mortality Q3CY13‐Q2CY16 22% 0.46 0.40 ‐0.22 0.00 6

(2) Outcomes: Readmission Q3CY13‐Q2CY16 22% ‐1.26 ‐0.70 ‐0.85 ‐0.03 7

(3) Outcomes: Safety Q1CY16‐Q4CY16 22% 0.45 ‐0.38 ‐1.22 ‐0.01 7

(4) Patient Experience Q1CY16‐Q4CY16 22% ‐1.68 ‐1.03 ‐0.59 0.00 11

(5) Process: Effectiveness Q1CY16‐Q4CY16 4% 0.33 ‐0.31 0.09 0.00 10

(6) Process: Timeliness Q1CY16‐Q4CY16 4% ‐0.63 ‐1.60 ‐0.94 0.03 6

(7) Efficiency: Imaging Q3CY15‐Q2CY16 4% ‐0.51 0.22 ‐1.71 0.01 4

Overall Summary Score 100% ‐0.48 ‐0.44 ‐0.73 N/A 51

Overall Star Rating 100% 2 Star 2 Star 2 Star

Notes:

Numeric scores represent the number of standard deviations above or below the National mean. Higher is betterAbove National Avg (4 Star)




Domain Measures Star Ratings VBP Cadiac Bundles Leapfrog

MORT‐30‐AMI x x x

MORT‐30‐STK x

MORT‐30‐PN x x

MORT‐30‐COPD x

PSI‐4‐SURG‐COMP x

MORT‐30‐HF x x

MORT‐30‐CABG x x

Mortality (22%

)

Measures included in the Mortality Domain

hospital‐level 30‐day risk‐standardized mortality rates

• GCMC and LMH/HP scores degraded from “statistically better than rest of nation” to “statistically no different”

• LMH/HP overall mortality domain is now numerically below the rest of the nation

• Since measure is a rolling 3-yr, the performance in the year added is worse than the performance in the year removed. It takes 3 yrs to remove bad performance year from data.

• If performance continues to erode, there is risk of falling to 1 Star performance, as the nation continues to improve.

• You’ve been hearing the importance of documentation and risk adjustment-this is why it matters

Changes in Mortality Domain Performance(in No. of Std. Deviations around national average – higher is better)

CCH Group

Score

GCMC Group

Score

LMH/HPMC

Group Score

0.46 0.40 ‐0.22

CCH Group

Score

GCMC Group

Score

LMH/HPMC

Group Score

0.45 0.82 0.68

Above National Avg (4 Star)




Performance Period = 3Q11 – 2Q14(no. of Std. Dev – higher is better)

Performance Period = 3Q13 – 2Q16(no. of Std. Dev – higher is better)

Delta:(no. of Std. Dev – higher is better)

0.01 ‐0.42 ‐0.9

Selected AMI Risk Factors involved in calculating the CMS’s “expected” mortality rate

28

GULF COAST MEDICAL CENTER LEE MEM HEALTH SYSTEMHospital Discharge Period: July 1, 2013 through June 30, 2016

Risk FactorAMI

Mortality: Hospital

AMI Mortality:

State

AMI Mortality: National

AMI Diff

Protein-Calorie Malnutrition (CC 21) 1% 5% 6% -5%Dementia or Other Specified Brain Disorders (CC 51-53) 15% 21% 19% -4%Congestive Heart Failure (CC 85) 24% 29% 29% -5%Acute Myocardial Infarction (CC 86) 6% 12% 13% -7%Dialysis Status (CC 134) 32% 40% 39% -7%

Table III.4: Distribution of Patient Risk Factors for the Condition-Specific 30-Day Risk Standardized Mortality Measures for AMI, COPD, HF, Pneumonia, and Stroke

Takeaway:Accurate DOCUMENTATION of risk‐factors also plays a role in our 30‐day risk‐standardized mortality rates and all our safety indicators

DOCUMENTATION CCG

29

BPA’s to improve Documentation

BPA Name Status Description Primary Trigger Comments

Acute MyocardialInfarction

In ProductionJune 2017

Offers selection of problems when missing

Elevated troponinFull Dose Heparin

36% acceptance (44/122) since 6/17

Congestive Heart Failure

In ProductionMay 2017

Offers selection of problems when missing(10% occurrence)

HF order set use 43% acceptance (66/155) since 5/17

Chronic Obstructive Pulmonary Disease

In ProductionMay 2017

Offers selection of problems when missing(6% occurrence)

COPD order set use


Body Mass Index In Production April 2016


Elevated BMI 58% acceptance (5809/9940) since 4/16

Anemia In ProductionJune 2017


Transfusion order for PRBC


End Stage Renal Disease

In ProductionJune 2017

Offers to call Renal Consult

Absence of consult with renal Dz

10% acceptance (3/31), Looking to improve filtering

Malnutrition In ProductionOctober 2017

Offer to review a matrix

RD flow row documentation

90% acceptance (28/31) since 10/5/17

See Appendix at end of presentation

31

BOARD OF DIRECTORS

INTEGRATING QUALITY & SAFETY PERFORMANCE IMPROVEMENT

(Chris Crawford, VP Standards & Quality)

Clinically Integrate Safety and Quality at

Lee Health

Chris Crawford, RNVice President, Standard and Quality

October 26, 2017

32

33

ACUTE CAREQUALITY SAFETY GOVERNANCE

Acute CareLeadershipCouncil

ClinicalConsensusGroups

ClinicalCollaboration

Council

ExecutiveQuality Safety

Council

Senior NurseLeadershipCouncil

QualitySafety

Framework

BOARD OF DIRECTORS

SAFETY ACTION PLAN & SAFETY CULTURE UPDATE

(Alex Daneshmand, D.O., Patient Safety Officer)

Safety ProgramBuilding Safety Action Plan

Together

K. Alex Daneshmand, DO, MBA, FAAPPatient Safety Officer

October 26, 2017

34

35

Safety Perception

36

Safety Perception

37

Safety Perception

Increase Safety Visibility

Safety Transparency

Improve Communication

Be Predictive

3

2

1

4

6

5 Make Safety Actionable

Set Goals and Measure It

39

Increase Safety Visibility

Launch A New Series of Safety Videos

Update Safety Newsletter to Contain Timely and Relevant Information

Safety Alert

Bring Errors to Front Line and Make Them Visible

1

40

Safety Transparency

Empower Front Line Staff To Monitor Safety

Help the Front Line to Discuss their Safety Concerns Openly

Let’s Be Up Front about Our Safety Record to Reinforce Confidence and Accountability

1

41

Safety Communication

Introduced TeamSTEPPS (Team Strategy & Tools to Enhance Performance and Patient Safety)

Supervisors and Managers to Close the Loop of Communication

Communicate Expectation and Goals

2

42

Safety Communication2

Education ModuleTo Become Safety Coaches

New Recognition Badges

Standardize Our Safety Coaches Participation

Closing the loop of Communication

43

Be Predictive

Respond to Near Misses and Pre‐cursor Events in Real Time

Create a Stress Model to Be Agile and Responsive

Use Pavisse to Find Commonality of Errors

Focus on Unsafe Behaviors at the Front Line

3

44

Make Safety Actionable4

1000 Unsafe Behavior

100 Near Misses

30 Precursor Events

1 Serious InjuryTypically

Documented

Typically Undocumented

45

Measure Safety

Agency for Health Research QualitySafety Culture Survey

Measure our Safety Continuously

Set Our Goals to Zero Harm

Achieve the highest grade possible on Leapfrog Safety Scoring

6

46

What is Next?

Step 5: Be Intentional with our Safety Efforts

Step 1: Support Front Line Staff and Their Safety Communication

Step 2: Making Safety Program Visible

Step 3: Be Transparent with Zero Harm Plan

Step 4: Be Predictive

Thank You

BOARD OF DIRECTORS

PATIENT EXPERIENCE – OUTPATIENT SURGERY CENTER (Kathy Fairfax, RN, MHA, CNOR, Acting Director, Surgery Center, Sanctuary)

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Outpatient Surgery Center at the Sanctuary:Patient SatisfactionWhat Matters?

Kathy Fairfax, RN, MHA

October 26, 2017

Our Score

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Who?

50

The PeopleRight Culture, Right Place, Right Time, Right Care

• Staff•Anesthesia• Surgeons

• Patients• Families

What and How?• Phone calls

• Email

• Contact information

• Anesthesia involvement

• Follow up phone call

• Follow up phone call from Anesthesia

• Efficiency

• Detail Oriented

• Thank you cards

• Hand made shawls and hats

• Surgeons

• Facility51

When?

Owning the patient experience

• Any time and Every time• Every interaction

52

Why?• Trust• Safety• Integrity• Empathy =RELATIONSHIPS

• Support• Rapport• Friend

53

So what matters?

• Any Thing and Every Thing• Any Time and Every Time

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Satisfaction Scores Over Time

55

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

110.0

Nov‐ 14…

Dec‐ 14…

Jan‐ 15…

Feb‐ 15…

Mar‐ 15…

Apr‐ 15…

May‐ 15…

Jun‐ 15…

Jul‐ 15…

Aug‐ 15…

Sep‐ 15…

Oct‐ 15…

Nov‐ 15…

Dec‐ 15…

Jan‐ 16…

Feb‐ 16…

Mar‐ 16…

Apr‐ 16…

May‐ 16…

Jun‐ 16…

Jul‐ 16…

Aug‐ 16…

Sep‐ 16…

Oct‐ 16…

Nov‐ 16…

Dec‐ 16…

Jan‐ 17…

Feb‐ 17…

Mar‐ 17…

Apr‐ 17…

May‐ 17…

Jun‐ 17…

Jul‐ 17…

Aug‐ 17…

Sep‐ 17…

Top Box Score‐Sanctuary Outpatient Surgery

Top Box 3 Yr Avg

Thank You

APPENDIX

57

-Patient Experience Domain-Pulmonary Embolism/Deep Vein Thrombosis

58

Patient Experience Domain

FY17 Exceeds 74.3%

FY17 Meets 71.1%

FYTD 68.8%

FMTD 69.6%

LH ADULT IP PATIENT EXPERIENCE

Measure of: Patient Experience

Owner: Lisa Sgarlata

HCAHPS Survey Scores % of Respondents Selecting Either 9 or 10

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP

% of Respondents selecting 9 or 10

Meets Goal

FY16

FY17

Safety Domain – Pulmonary Embolism/Deep Vein Thrombosis (PE/DVT)

Readmissions

61

Readmissions Domain - All Cause 30-day Readmissions

FY17Exceeds 14.60%FY17Meets 15.50%

FYTD 16.25%MTD 17.42%16.25%

0%

5%

10%

15%

20%

Oct(364/2140)

Nov(377/2188)

Dec(411/2412)

Jan(414/2708)

Feb(398/2610)

Mar(410/2777)

Apr(401/2443)

May(387/2324)

Jun(360/2067)

Jul (/) Aug (/) Sep (/)

% 30‐day Readmission

FY2016 FY2017 FY2017 SCORECARD Meets

(ExcludesNormalNewborns[DRG795])Measureof:ClinicalIntegration

Owner:Dr.Kolsun

MEDICAREONLY

LH30DayAcuteCareInpatientReadmission%

Mortality Data

65

LMH/HPMC – PN Mortality Risk Factors

GCMC – STK Mortality Risk Factors

CCH – STK Mortality Risk Factors

BOARD OF DIRECTORS

SYSTEM PERFORMANCE INDICATORS (Marcelo Zottolo, System Director Process Analytics)

(ACCEPT)

#2

77

2 R

ev. 0

1/1

7

System BODPerformance Indicators

3rd Quarter FY 2017April – June 2017

•The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations.


Page 70

KEY: Stars assigned on Current Quarter values *** Better than Expected ** As Expected +/- 5% variance *Worse than Expected

Performance Measures3rd Quarter Fiscal Year 2017 (Apr – Jun 2017)

Performance Measures3rd Quarter Fiscal Year 2017 (Apr – Jun 2017)

KEY: Stars assigned on Current Quarter values *** Better than Expected ** As Expected +/- 5% variance *Worse than Expected

Data:

• Indicator Description: Monthly monitor of the health system’s rolling 12 month Serious Safety Event Rate (SSER) and number of serious safety events (SSEs)

• Formula: ([rolling 12 month number of serious safety events / rolling 12 month adjusted patient days] * 10,000)

• Goal: < 0.06 SSEs / 10,000 adjusted patient days

• Why track: Safety events cause increased risk and dissatisfaction among patient populations and increased cost to the health systemand patient.

Current Status:

3rd Quarter FY17 (through Jun-17)

• System: 0.053 SSEs / 10,000 adjusted patient days(3 SSEs / 566,746 adjusted patient days)

• Cape: 0.000 SSEs / 10,000 adjusted patient days(0 SSEs / 117,453 adjusted patient days)

• HealthPark: 0.000 SSEs / 10,000 adjusted patient days(0 SSE / 163,696 adjusted patient days)

• Lee: 0.174 SSEs / 10,000 adjusted patient days(2 SSEs / 114,704 adjusted patient days)

• Gulf Coast: 0.068 SSEs / 10,000 adjusted patient days(1 SSE / 147,167 adjusted patient days)

Governing Body:

• Executive Quality & Safety Council

= FavorableQ: LEE HEALTH – SERIOUS SAFETY EVENT RATE

InternalPage 72

EQSC Indicator

Event Rate Target (0.06)

Page 73

Event Rate Target (0.06) Event Rate Target (0.06)

Event Rate Target (0.06) Event Rate Target (0.06)

Page 74

SQSMC Indicator

PCM‐01 – Elective Delivery Prior to 39 Weeks data is obtained from chart abstraction

of a sampling of cases

VALUE BASED PURCHASINGPRENATAL CARE – ELECTIVE DELIVERY PRIOR TO 39 COMPLETE WEEKS GESTATION

May – Jun-17 Data Pending Chart Abstraction

Appendix(Supplemental Charts)

Page 75

Page 76

Page 77

Beginning April 2016, the “Acute Care & Rehab – Severity II Medication Error” indicator was revised to exclude the outcome population of “Monitoring”

(outcome of monitoring moved to the Severity I outcome category).

Page 78

Page 79

Page 80

Page 81

Page 82

Page 83

Page 84

PERFORMANCE IMPROVEMENT METRICCURRENT

GOALNATIONAL AVERAGE

GOAL SOURCEBUSINESS / CLINICAL

OWNER

LAST REVISION

DATE

SQSMC INDICATOR

BOD INDICATOR

ACUTE CARE & REHAB - SEVERITY II MEDICATION ERRORS (excluding GCHSWF)</=1.5 errors/10,000 pt days

John Armitstead,System Pharmacy Director

John ArmitsteadQtr 3 FY 2016

(Apr-16)X X

ACUTE CARE & REHAB - SEVERITY III MEDICATION ERRORS (excluding GCHSWF)0 errors/

10,000 pt daysSteve Kessinger,

CCH Pharmacy DirectorJohn Armitstead

Qtr 1 FY 2002(Oct-01)

X X

EMERGENCY DEPARTMENT - "LEFT BEFORE EVALUATED" & "LEFT BEFORE TREATMENT" INCIDENTS </= 2% (?) Lisa SgarlataQtr 2 FY 2006

(Jan-06)X X

EMERGENCY DEPARTMENT (ED-2b) - ADMIT DECISION TIME TO ED DEPARTURE TIME FOR ADMITTED MEDICARE PATIENTS

100 minutes 100 minutes Hospital Compare Report Lisa Sgarlata Qtr 3 FY 2016 X X

EMERGENCY DEPARTMENT (OP-18b) - MEDIAN TIME FROM ED ARRIVAL TO ED DEPARTURE FOR DISCHARGED MEDICARE ED PATIENTS

148 minutes 148 minutes Hospital Compare Report Lisa Sgarlata Qtr 3 FY 2016 X X

LMHS - LIFELINK ORGAN DONOR CONVERSION RATE 75% 75%US Dept of Health & Human Services

http://www.organdonor.gov/dtcp/dtcp.htmlChris Crawford

Qtr 1 FY 2016(Oct-15) X

LMHS - SERIOUS SAFETY EVENT RATE</= 0.06

SSEs/10,000 APD

Planning & StrategySystem Strategic Initiatives Scorecard

http://intranet1/stratplan/PDF/Scorecard/FY2016/Scorecard_Jan_BOD__IntraLee_v3.pdf

Dr. DaneshmandQtr 3 FY 2015

(Apr-15)X X

NDNQI ACUTE CARE - HOSPITAL ACQUIRED PRESSURE ULCERS STAGE II & ABOVE 2.22%Quarterly NDNQI Report (avg of Acute Care

mean)Lisa Sgarlata

Qtr 1 FY 2016(Oct-15)

X X

NDNQI REHAB - UNIT ACQUIRED PRESSURE ULCERS STAGE II & ABOVE 0.65% Quarterly NDNQI Report (Rehab Unit mean) Lisa SgarlataQtr 1 FY 2016

(Oct-15)X X

SYSTEM ACUTE CARE - HAI CATHETER -ASSOCIATED URINARY TRACT INFECTIONS (CAUTI)SIR = 0.369

70%-ileSIR = 0.822

50%-ileFY 2019 VBP Domain Weighting Report Stephen Streed

Qtr 2 FY 2017(Mar-17)

X X

SYSTEM ACUTE CARE - HAI CENTRAL LINE-ASSOCIATED BLOOD STREAM INFECTIONS (CLABSI)SIR = 0.559

70%-ileSIR = 0.860


Qtr 2 FY 2017(Mar-17)

X X

SYSTEM ACUTE CARE - HAI CLOSTRIDIUM DIFFICILE INFECTIONS (C. DIFF.)SIR = 0.924

50%-ileSIR = 0.924


Qtr 2 FY 2017(Mar-17)

X X

SYSTEM ACUTE CARE - HAI COLORECTAL SURGICAL SITE INFECTIONS (SSIs)SIR = 0.783

50%-ileSIR = 0.783


Qtr 2 FY 2017(Mar-17)

X X

SYSTEM ACUTE CARE - HAI METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS INFECTIONS (MRSA)

SIR = 0.85450%-ile

SIR = 0.85450%-ile

FY 2019 VBP Domain Weighting Report Stephen StreedQtr 2 FY 2017

(Mar-17)X X

SYSTEM ACUTE CARE - HOSPITAL-ACQUIRED FALLS & TRAUMA PER 1,000 DISCHARGES 0.55 Leapfrog Report (March 2016) Lisa SgarlataQtr 2 FY 2015

(Jan-15)X

SYSTEM ACUTE CARE - PATIENT RESTRAINTS PER 1,000 DAYS 14.0 N/AInternal source provided by Senior Nursing

Leadership CouncilLisa Sgarlata

Qtr 4 FY 2015 (Jul-27)

X

VBP - PRENATAL CARE - ELECTIVE DELIVERY PRIOR TO 39 COMPLETE WEEKS GESTATION 2.04% FY 2018 VBP Domain Weighting Report Carol LawrenceQtr 1 FY 2016

(Oct-15)X X

Thank You

BOARD OF DIRECTORS

ANNUAL ETHICS REPORT (Rev. Cynthia Brasher, MDiv, BCC)

(ACCEPT)

Lee Memorial Health System Board of Directors Updated 3/2/17

BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS RECOMMENDED FOR BOARD ACTION

(Action includes Acceptance, Approval, Adoption, etc)

Keep form to one page, EMAIL to: [email protected] by Noon Eight (8) days PRIOR to presenting.

DATE: October 26, 2017 LEGAL SERVICE REVIEW? YES__ NO_x_ SUBJECT: Annual Lee Health Ethics Report REQUESTOR & TITLE: Cynthia Brasher, MDiv, BCC, System Director, Spiritual Services

PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation) Previous Board Action was acceptance of the annual Lee Health Ethics report for 2016. SPECIFIC PROPOSED MOTION: The proposed motion is to accept the annual Lee Health Ethics report for 2017. FINANCIAL IMPLICATIONS Budgeted Account ____ Non-Budgeted _x___ (Annual Project Budget and Total Project Budget) N/A STAFFING & OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) Employees and community members from multi-disciplines serve on a voluntary basis in the ethics process. Members remain committed to ethics education and called ethics meetings for ethics case reviews in advocating for what is in the best interest of the patient. PURPOSE/REASON FOR RECOMMENDATION The purpose is to provide an overview of the system ethics process for the last year.

SUMMARY (including alternatives considered, Pros and Cons) The ethics process continues to be maintained at a system level with sustained membership. New members have been recruited or have expressed an interest in membership. Education themes address population diversity and safety, and/or have been informed by state and national conferences. Education meetings have provided dialogue with identified opportunities for additional education on Advance Directives and Allow Natural Death. A new education topic, “Collaborative Compassion,” is being scheduled by the ethics consult groups in the organization at the recommendation of the ethics council.

LEE HEALTH Lee County, Florida

M E M O R A N D U M TO: Board of Directors FROM: Rev. Cynthia W. Brasher, MDiv, BCC

System Director, Spiritual Services DATE: October 26, 2017 SUBJECT: Annual Ethics Consultation Groups / Ethics Council Update

(November 2016 through October 2017) Co-Chairs for Cape Coral Hospital: Rev. Denise Sawyer, MDiv, BCC; Kimberly Volgelbach, ARNP Chair for HealthPark Medical Center, Lee Memorial Hospital, and Lee Health Council: Rev. Cynthia Brasher, MDiv, BCC Co-Chairs for Golisano Children’s Hospital of Southwest Florida: Chaplain Susan Crowley, MA, BCC; William F. Liu, MD Chair for Gulf Coast Medical Center: Stephen Wilczynski, MD Fourteen scheduled Ethics Consultation Group meetings were held throughout the system and one Ethics Council meeting occurred since the last report to the Board of Directors. Ethics Council meetings and Pediatric Ethics Consult Group meetings are scheduled to occur bi-annually. Additional Ethics Consultation Group meetings rotate on a monthly basis. Ethics Consult Groups also are called upon as needed for additional Ethics Consult reviews. Minutes of all meetings are kept in the Spiritual Services Department at HealthPark Medical Center. Membership rosters for Cape Coral Hospital, Golisano Children’s Hospital of Southwest Florida, Gulf Coast Medical Center, HealthPark Medical Center, Lee Memorial Hospital Ethics Consult Groups and Lee Health Ethics Council are updated and filed by the Spiritual Services Department. An outline of the educational presentations and where they were held follows:

LECTURE TITLES

CAPE CORAL HOSPTAL

GOLISANO CHILDREN’S

HOSPITAL OF SOUTHWEST FLORIDA

GULF COAST MEDICAL

CENTER

HEALTHPARK MEDICAL

CENTER


“Case Study of Adult Sibling

Incest”

November 23, 2016

12:30 p.m. – 1:45 p.m. Guillermo Philipps, MD

Pediatric Neurologist LPG - Golisano Children’s

Hospital of Southwest Florida

“Case Study: Care of Transsexual Persons”

November 30, 2016

12:15 p.m. – 1:15 p.m. Rev. Mason Jackson, MDiv, BCC

Chaplain, Gulf Coast Medical Center

January 17, 2017

12:30 p.m. – 1:30 p.m. Rev. Mason Jackson, MDiv, BCC

Chaplain, Gulf Coast Medical Center

“Climate Change and

Bioethics”

November 17, 2016

12:00 p.m. – 1:00 p.m. Rev. Denise Sawyer, MDiv, BCC

Chaplain, Cape Coral Hospital

March 8, 2017

5:30 p.m. – 6:30 p.m Rev. Denise Sawyer, MDiv, BCC


June 7, 2017



April 18, 2017



LECTURE TITLES

CAPE CORAL HOSPTAL

GOLISANO CHILDREN’S

HOSPITAL OF SOUTHWEST FLORIDA

GULF COAST MEDICAL

CENTER

HEALTHPARK MEDICAL

CENTER


“Aging in Place: An Overview”

December 14, 2016

5:30 p.m. – 6:30 p.m. Dawn Moore, Case Manager

Senior Care Choices, Lee Health

“Morality and Ethics”

February 16, 2017



“Palliative Care: What We Do”

May 18, 2017

12:00 p.m. – 1:00 p.m. Kimberly Vogelbach, ARNP,

Advanced Provider/Palliative Care

“The Right of Informed Refusal – An Obstetrical Case Study”

May 24, 2017

12:30 p.m. – 1:45 p.m. William S. Binder, MD –

Neonatology, Pediatrix Medical Group of Southwest Florida

“Allow Natural Death/Do Not Resuscitate/Restrictive

Resuscitation”

June 14, 2017

5:30 p.m. – 6:30 p.m. Dr. Steve Wilczynski, MD, Critical

Care/Pulmonary Medicine and Rev. Cynthia Brasher, MDiv, BCC System Director, Spiritual Services

“Allow Natural Death/Do Not Resuscitate – An Overview”

July 18, 2017

12:30 p.m. – 1:30 p.m. Rev. Cynthia Brasher, MDiv, BCC System Director, Spiritual Services

“Safety - Back to Basics”

August 17, 2017

12:00 p.m. – 1:00 p.m. Jeri Grimes, Director

Volunteer Resources and Auxiliary

“Jehovah’s Witnesses Hospital Liaison Committee Functions

and Perspectives”

Scheduled for:

November 15, 2017 Min. Amos O Frazier, Jehovah’s

Witness Hospital Liaison Committee Representative

“Collaborative Compassion”

Scheduled for:

December 6, 2017 12:15 p.m. – 1:15 p.m.

Rev. Mike Warthen, MDiv, BCC Chaplain, Lee Memorial Hospital

LOCATION/GROUP DATE ATTENDANCE

CCH - ETHICS CONSULT 11/17/16 MEMBERS 7

GUESTS 0

ATTENDANCE TOTALS 2/16/17 MEMBERS 8

MEMBERS: 26 GUESTS 1

GUESTS: 1 5/18/17 MEMBERS 7

GUESTS 0

8/17/17 MEMBERS 4

GUESTS 0


GCH PEDS ETHICS CONSULT 11/23/16 MEMBERS 5

ATTENDANCE TOTALS GUESTS 0

MEMBERS: 13 5/24/17 MEMBERS 8

GUESTS: 0 GUESTS 0


GCMC – ETHICS CONSULT 12/14/16 MEMBERS 10

GUESTS 1




GUESTS 2

LOCATION/GROUP DATE TOTAL

HPMC ETHICS CONSULT 11/30/16 MEMBERS 6

GUESTS 1



GUESTS: 3 12/6/17 MEMBERS

TBD GUESTS


LMH ETHICS CONSULT 1/7/17 MEMBERS 4

GUESTS 1




GUESTS 0


LEE HEALTH ETHICS COUNCIL 10/5/17 MEMBERS 6

GUESTS 0

ATTENDANCE TOTALS

MEMBERS: 6

GUESTS: 0

FY 16/17 TOTAL MEMBERS: 91

FY 16/17 TOTAL GUESTS: 10

ADJOURNMENT

BOARD OF DIRECTORS

DATE OF THE NEXT REGULARLY SCHEDULED

QUALITY, SAFETY & EDUCATION & FULL BOARD MEETING

February 22, 2018

Gulf Coast Medical Center Medical Office Building

13685 Doctors Way Ft. Myers, FL 33912

LIAISON TO CHAIRMAN:

Lee Health (Health System)

FULL BOARD OF DIRECTORS MEETING

Thursday, October 26, 2017

BOARD CHAIRMAN: Sanford Cohen, M.D.

BOARD OF DIRECTORS

PLANNING & FULL BOARD MEETING MINUTES OF 10/12/17

(APPROVE)


PLANNING BOARD AND FULL BOARD OF DIRECTORS MEETING MINUTES

Thursday, October 12, 2017

LOCATION: Gulf Coast Medical Center, Community Room, 13681 Doctors Way, Fort Myers, FL 33912 MEMBERS PRESENT: Sanford N. Cohen, M.D., Board Chairman; Donna Clarke, Board Vice Chairman; David Collins, Board Treasurer; Therese Everly, Board Secretary; Steven Brown, M.D., Board Member; Chris Hansen, Board Member; Jessica Carter Peer, Board Member; Stephanie Meyer, BSN, RN, Board Member MEMBERS ABSENT: Nancy McGovern, RN, MSM, Board Member; Diane Champion, Board Member

NOTE: Documents referred to in these minutes are on file by reference to this meeting date in the Office of the Board of Directors and on the Board of Directors website at www.leehealth.org/boardofdirectors, for public inspection.

SUBJECT DISCUSSION ACTION FOLLOW-UP

MEETING CALLED TO ORDER

The LEE HEALTH PLANNING BOARD & FULL BOARD OF DIRECTORS MEETINGS

were CALLED TO ORDER at 1:00 p.m. by Sanford Cohen, M.D., Board Chairman.

INVOCATION AND

PLEDGE OF ALLEGIANCE

Rev. Denise Sawyer, MDiv, BCC, gave the Invocation, followed by the Pledge of Allegiance.

PUBLIC INPUT None at this time.

RECOGNIZE 2016/2017

AUXILIARY PRESIDENTS

Jon Cecil introduced Auxiliary President Jim Andrews, Lee Memorial and Eileen Winter, Incoming Auxiliary President, Gulf Coast Medical Center and Jeri Grimes, Director of Volunteer Services, Cape Coral Hospital.

Chris Hansen arrived at 1:10 p.m.

A motion was made by Jessica Carter Peer to accept the Auxiliary President Reports.

The motion was seconded by Chris Hansen and carried with no opposition.

PHYSICIAN

LEADERSHIP COUNCIL REPORT

William Hearn, D.O. presented the Physician Leadership Council Report.

A motion was made by Chris Hansen to accept the Physician Leadership Council Report.

The motion was seconded by Therese Everly and carried with no opposition.

PRESIDENT’S REPORT Larry Antonucci, M.D. introduced Bob Boswell, LeeSar CEO/President and

presented the President’s Report.

CHAIRMAN TO

PLANNING LIAISON The gavel was turned over to PLANNING Liaison, Donna Clarke, to

CONVENE the PLANNING portion of the meeting at 1:57 p.m.

COCONUT RD/US 41 PROPERTY PURCHASE

Kevin Newingham and Suzanne Bradach asked for approval of the Coconut Rd/US 41 Property Purchase. Discussion followed.

A motion was made by Stephen Brown to (1) approve the terms attached Assignment and Assumption of Contract of Purchase and Sale of Property and Assignment and Assumption of Commercial Contract for the purchase two adjacent parcels of land located at the corner of Coconut Road and US 41 in Estero, Florida where one parcel is 28.9 acres of real property with a purchase price of nine million five hundred fifty thousand dollars and 00/100 ($9,550,000.00) and the other parcel is 14.41 acres of real property at a purchase price of Eight Million Dollars ($8,000,000) for a total acquisition of 43.31 acres of real property and a total purchase price of seventeen million five hundred fifty thousand dollars and 00/100 ($17,550,000.00).

LEE HEALTH PLANNING & FULL BOARD OF DIRECTORS MEETING MINUTES

Thursday, October 12, 2017 Page 2 of 3



Therese Everly stated she would like Administration to come back with the next steps following the purchase of this property.

The motion was seconded by Stephanie Meyer.

After a few minutes of discussion, Stephen Brown made a motion to call the question. Donna Clarke called for a vote on calling the question with Stephen Brown, Stephanie Myers, David Collins, Dr. Cohen, Therese Everly, Chris Hansen and Jessica Carter Peer in support of calling the question.

The motion made by Stephen Brown and seconded by Stephanie Meyer was approved with David Collins opposed.

An amended motion was made by Stephen Brown to (2) authorize the President and Chairman to execute the assignments and/or necessary legal documents after the Board approves the purchase and upon final review and approval by LMHS Legal Counsel and Board Counsel.

The motion made by Stephen Brown and seconded by Stephanie Meyer was approved with no opposition.

Administration

/Next Steps/ TBD

GCMC SKILLED

NURSING UNIT LEASE Dave Cato and Troy Churchill asked for approval of the GCMC Skilled Nursing Unit Lease.

Discussion followed.

A motion was made by Sanford Cohen to (1) approve the lease between Lee Health and Plantation Medical Center SNU, LLC of approximately 57,650 sf for use of a skilled nursing unit located at 13960 Plantation Road with the following significant terms of: base rent of $35.50/sf; 20 year initial term with two 5 year renewal options; 2.5% annual escalation in rent; options to purchase available in year 10 and beyond; along with other terms as set forth in the attached Lease.

The motion was seconded by Chris Hansen and carried with David Collins and Therese Everly opposed.

STRATEGIC

SCORECARD UPDATE Kevin Newingham presented a Strategic Scorecard Update.

Stephen Brown stated that patient satisfaction needs to be more of a priority.

PLANNING LIAISON TO

CHAIRMAN

The next LEE HEALTH Planning Board Meeting is: Thursday January 11, 2018, at 1:00 p.m.

Gulf Coast Medical Center, Medical Office, Boardroom 13685 Doctors Way, Fort Myers, FL 33912

The gavel was turned over to the Board Chairman, Sanford Cohen, to RECONVENE the FULL BOARD portion of the meeting at 3:17 p.m.

Dr. Cohen called for RECESS at 3:18 p.m., meeting RECONVENED at 3:30 p.m.

FINANCE AND FULL BOARD MEETING

MINUTES OF 9/28/17

Dr. Cohen asked for approval of the Finance and Full Board Meeting Minutes of 9/28/17.

A motion was made by Therese Everly to approve the Finance and Full Board Meeting Minutes of 9/28/17.

The motion was seconded by Donna Clarke and carried with no opposition.

PSN AND ACO:

UPDATE AND NEXT STEPS

John Chomeau presented an update regarding the PSN and ACO.

Jessica Carter Peer departed at 4:08 p.m.

BEHAVIORAL HEALTH

STRATEGY UPDATE John Chomeau and Lisa Sgarlata presented a Behavioral Health Strategy Update.

OLD BUSINESS None at this time.

LEE HEALTH PLANNING & FULL BOARD OF DIRECTORS MEETING MINUTES

Thursday, October 12, 2017 Page 3 of 3



NEW BUSINESS David Berger informed the Board that the CME (Continuing Medical Education) program has lost their Director and they are in need of another and this should be a priority as Education is one of our core values.

BOARD MEETING

CRITIQUE Board Members believed the meeting went well, great presentations and dialogue.

BOARD OF DIRECTORS REPORTS

Stephen Brown reminded Board Members of the Doc Coggins Gala this Saturday and thanked Board Staff for their work.

Donna Clarke apologized for missing the last Board Meeting due to flight issues returning from the Epic Conference.

David Collins apologized that he could not attend the Doc Coggins Gala this Saturday and reminded Board Members of the Hope Clubhouse Annual Mental Health Luncheon at Broadway Palm on October 30th.

Therese Everly attended the launching of Lee Health’s Walk Club at Cape Coral Hospital, Lean Report Meeting; thanked Ben Spence for being engaged in the Clinical Processes. Therese toured the Lee Health Behavioral Health Center, attended the March of Dimes Event and announced next year’s chair will be a LH NICU nurse and her spouse.

Chris Hansen informed the Board of a free 5 CE event provided by Park Royal and others. He also informed the Board of two events, “Hope, A time for community action” on October 26th and the Hope Clubhouse event on October 30th, he will send the information to the Board Staff if anyone would like more information.

Dr. Cohen informed the Board of an impressive report with data gathered by Lee Health patients on another way Epic is helping by alerting surgeons when a patient could potentially develop kidney issues after having cardiac surgery.

NEXT REGULAR

MEETING The next LEE HEALTH

QUALITY, SAFETY & EDUCATION & FULL BOARD OF DIRECTORS MEETINGS

will be held on October 26, 2017, at 1:00 p.m. in the Gulf Coast Medical Center, Medical Office Building, Boardroom

13685 Doctors Way, Fort Myers, FL 33912

ADJOURNMENT The LEE HEALTH SYSTEM PLANNING BOARD

& FULL BOARD OF DIRECTORS MEETINGS ADJOURNED at 4:51 p.m.

by Sanford Cohen, M.D., Board Chairman.

Minutes were recorded by Jennifer Zager, Assistant to the Board of Directors

________________________________________

Therese Everly Date approved Board Secretary

BOARD OF DIRECTORS

RISK MANAGEMENT REPORT (Mary Lorah, Risk Manager II)

(ACCEPT)

Lee Memorial Health System Board of Directors Updated 3/2/17

BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS RECOMMENDED FOR BOARD ACTION

(Action includes Acceptance, Approval, Adoption, etc)

Keep form to one page, EMAIL to: [email protected] by Noon Eight (8) days PRIOR to presenting.

DATE: 10/26/2017 LEGAL SERVICE REVIEW? YES__ NO__ SUBJECT: Quarterly Risk Management Report REQUESTOR & TITLE: Mary McGillicuddy, Chief Legal Officer and Mary Lorah, Risk Manager

PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation) The Board of Directors reviews the Quarterly Risk Management Report on a quarterly basis SPECIFIC PROPOSED MOTION: Motion to approve the Quarterly Risk Management Report as presented. This request supports the following Strategic Initiative(s): Service Safety & Quality and Financial Viability

FINANCIAL IMPLICATIONS Budgeted Account ____ Non-Budgeted ____ (Annual Project Budget and Total Project Budget) None STAFFING & OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) None PURPOSE/REASON FOR RECOMMENDATION See Presentation

SUMMARY (including alternatives considered, Pros and Cons) This Quarterly Risk Management Report provides a summary of information about activities of the Risk Management program, including the following:

Incident and Safety Reporting rate per 1,000 patient days Impact per 1,000 patient days Categories of reports Risk Management participation in LMHS System Committees and Education Liability Summary Goals

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

#3400.159 Rev. 10/16

Risk Management Report to the Board of Directors

July – September 2017

The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded PatientSafety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations.


Risk Management Program Elements

The Risk Management Program is designed to identify, evaluate and reduce the risk of injury to the patients, personnel, visitors and to reduce the risk of loss to the health system. Risk Managers:

Review reports, conduct investigations and analyze events in an effort to reduce risks to patients and the frequency and severity of medical malpractice claims; and

Investigate patient care complaints, provide education, and provide direction in regards to regulatory compliance.

This report includes Risk Management activities for the quarter and includes a summary of patient safety events and reporting rates; adverse incidents under Florida law; impact analysis; report categories; education; claims; general activities; and goals.

1The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded PatientSafety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations.


Patient Safety Evaluation System

Please Note: Separate from Florida law program requirements, Risk Managers play an integral role in the health system’s Patient Safety Evaluation System, a voluntary program created by federal law. Employees are encouraged to report patient safety or quality concerns by filing a Patient Safety Report which are utilized by Risk Managers who participate in health system patient safety initiatives



Patient Safety Reporting RatesThis graph shows event and report rates for the system for the last 12 months. The following page shows the reporting rates for each facility

3

Total Number of reports for the fourth quarter FY2017 was 2922


0

5

10

15

20

25

30

35

40

45

50

Oct‐16 Nov‐16 Dec‐16 Jan‐17 Feb‐17 Mar‐17 Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17

Rate per 1000 Patient Days

Lee Memorial Health System

LMHS Linear (LMHS)



Reporting Rate (continued)

0

10

20

30

40

50

Rate per 100

0 Pa

tient Days

HealthPark Medical Center

HPMC Linear (HPMC)

0

10

20

30

40

50

Oct‐16

Nov‐16

Dec‐16

Jan‐17

Feb‐17

Mar‐17

Apr‐17

May‐17

Jun‐17

Jul‐17

Aug‐17

Sep‐17

Rate per 100

0 Pa

tient Days

Gulf Coast Medical Center

GCMC Linear (GCMC)

0

10

20

30

40

50

Oct‐16

Nov‐16

Dec‐16

Jan‐17

Feb‐17

Mar‐17

Apr‐17

May‐17

Jun‐17

Jul‐17

Aug‐17

Sep‐17Ra

teper 1

000 Pa

tient Days

Cape Coral Hospital

CCH Linear (CCH)

0

10

20

30

40

50

Rate per 100

0 Pa

tient Days

Lee Memorial Hospital

LMH Linear (LMH)

0

10

20

30

40

50

May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17Rate per 1000 Patient Days

Golisano Children's Hospital

Series1 Linear (Series1)


AnalysisThis graph reflects the percentage of reports that have no impact on the patient.

The graph for the third quarter indicates that 83.20% (2431) of the reports received involve situations which had no impact on the patient.

Reporting “near misses” is highly encouraged to identify potential areas of improvement. This information allows us to provide data used in our quality improvement activities throughout the system.


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percent of reports without im

pact

LMHS Linear (LMHS)


AnalysisThis graph reflects the reporting rate per 1000 patient days and the rate of

patient impact for the four facilities during the quarter.

6


0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

CCH HPMC LMH GCMC GCHSWF

Reporting Rate Impact Rate


CategoriesThis table shows the rate for the categories of reports from July through September 2017 at all five facilities. Rates per 1000 Patient Days are utilized to be consistent with other system reporting. 95% of all reports fall under the Patient Safety section. The top five Patient Safety related events include:CareOtherIV ComplicationsMedication or Other SubstancePatient Falls

More than 75% of all reported occurrences fall within one of these five categoriesDuring this quarter there was one adverse incident reported to AHCA


Care, 547

Other, 508

IV Complication, 431

Medication or Other Substance, 422

Patient Falls, 357

0 100 200 300 400 500 600

Taxonomy Type Total Rate

Adverse Drug Reaction ADR, confirmed 13 0.14

ADR, suspected 14 0.15

Totals 27 0.29

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA Electronic Data Interchange 2 0.02

HIPAA Privacy 8 0.09

Totals 10 0.11

LH - Patient Safety Blood or Blood Product 24 0.26

Care 547 5.86

Device or Medical/Surgical Supply... 47 0.50

Environment 20 0.21

Fall 357 3.82

IV Complication 431 4.62

Laboratory 209 2.24

Medication or Other Substance 422 4.52

Other 508 5.44

Perinatal 63 0.67

Pressure Injury/Ulcer 9 0.10

Radiology 32 0.34

Surgery or Anesthesia 99 1.06

Totals 2768 29.65

Security, Operations and Environment

Cleanliness 1 0.01

Dietary 3 0.03

Equipment 10 0.11

Hazard or Disaster 10 0.11

Other 3 0.03

Process 19 0.20

Property and Security 24 0.26

Work Place Violence 3 0.03

Totals 73 0.78

Visitor Safety Altercation 1 0.01

Exposure 1 0.01

Fall 34 0.36

Other 8 0.09

Totals Totals 44 0.47

Grand Total 2922

Reporting Rate 31.3


8

Risk Management Orientation for new hires

GCMC Safety Coaches – Pavisse Reporting

CCH Safety Coaches – Pavisse Reporting

HPCC Defensible Documentation

GCMC Defensible Documentation

Equipment and Medication Safety for Cardiac CathLab Staff

Patient Safety for the Dietician

Monthly Safety updates to the Clinical Practice Council

Education Activities


9

Risk Management ActivitiesContinued participation in system patient safety

activities including: Policy & Procedure Committee Daily Safety Check-In Calls System Medication Safety Committee Campus Specific Medication Safety Work Teams Ethics Committee Executive Quality Safety Management Council Participated in various Root and Apparent Cause Analysis

Teams Emergency Dept and EMS committee to determine

appropriate disposition of adult and child Proactive Drug Diversion Surveillance & Prevention PI Team Patient Care Services Staffing Committee PDCA Care of the Deceased NDNQI Nurse Leader Scorecard Development Campus Specific Quality Committees Committee to Determine Notice of Child’s Death to the ME


LiabilityThe fourth fiscal quarter 2017 (July - September, 2017) ended with 36 pending claims. The quarter saw 6 claims closed and 7 claims opened. Malpractice prevention, patient safety and quality of care improvement continue to be the primary focus of the Health System’s risk managers.


0

5

10

15

20

25

30

35

40

45

FY15Q1 FY15Q2 FY15Q3 FY15Q4 FY16Q1 FY16Q2 FY16Q3 FY16Q4 FY17Q! FY17Q2 FY17Q3 FY17Q4

Number of Cases

Number of Cases Linear (Number of Cases)


Risk Management Goals

11

• Continue to track and trend patient safety events, adverse incidents, provide summary data and work closely with various departments and committees engaged in performance improvement and patient safety activities.

• Continue to work with Education and Organizational Development and management staff to assure that all employees are meeting the annual education requirement for risk management and to provide a module to meet the annual requirement.

• Continue to utilize pre‐litigation procedures to resolve meritorious claims in a timely manner.

• Continue to collaborate with others in the Health System with regard to patient safety initiatives and make recommendations based on trends.



Thank You


BOARD OF DIRECTORS

MEDICAL STAFF RECOMMENDATIONS

(APPROVE)

1. Lee Memorial Hospital

2. Cape Coral Hospital

3. Gulf Coast Medical Center

4. HealthPark Medical Center

5. Golisano Children’s Hospital of SWFL


LEE HEALTH

Lee County, Florida

#1 M E M O R A N D U M

To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Date: October 18, 2017 Subject: Lee Memorial Hospital Medical Staff Recommendations The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment: a. Melanie Altizer, M.D. – OB/Gyn b. Peter Ameglio, M.D. – Orthopedic Surgery c. David Gavin, D.P.M. – Podiatry d. Morris Gieselman, M.D. – Emergency Medicine e. Jacqueline Hidalgo, Psy.D. – Psychology

2. Telemedicine Appointment – Privileges Only:

a. Muhammad Masud, M.D. – Teleneurology 3. Change of Status:

a. Diana DeVall, M.D. – OB/Gyn, Honorary 10-01-17 4. Resignation:

a. A. Catherine David, D.P.M. – Podiatry, effective 10-01-17 b. James Butler, D.O. – Cardiology, effective 09-28-17 c. Frances Romero, M.D. – Family Medicine, effective 08-31-17

5. First Year Completions – Active Status:

a. Steven Woodring, D.O. – Anesthesiology 6. First Year Completions – Associate Status:

a. Daniel Black, D.P.M. – Podiatry b. Joseph Freedman, M.D. – Cardiology c. Amy Roth, D.O. – Internal Medicine d. Sharmila Tilak, M.D. – Internal Medicine

Memorandum to Board of Directors - LMH October 18, 2017 Page 2 of 2


7. Allied Health Practitioners: a. Carrie Bauer, PA – Radiation Therapy Services b. Ian Black, PA – LMHS ER Physicians c. Charles Crouse, CRNA – US Anesthesia Partners-FL d. Tilia Gonzalez, PA – Orthopedic Specialists of SW FL e. Robert Haynes, Jr., PA – LPG Trauma Surgeons f. Laverne Jones, ARNP – LPG Neurology g. Irene Julian, PA – GI Surgical Specialists h. Linda Mondragon, PA – Lee Community Healthcare – Dunbar i. Melinda Rakesmith, CRNA – US Anesthesia Partners-FL j. Amber Ramsay Mason, CRNA – US Anesthesia Partners-FL k. Michelle Tolar, ARNP – LPG Cardiothoracic Surgery

8. Allied Health Practitioner – Sponsor Change:

a. Melinda Cole, ARNP – Heart & Vascular Institute b. Amy Riddle, ARNP – Heart & Vascular Institute

Approved by the Board of Directors – October 26, 2017

________________________________________________ Sanford N. Cohen, M.D., Chairman - Board of Directors




To: Board of Directors

From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services

Subject: Cape Coral Hospital Medical Staff Recommendations

Date: October 18, 2017

The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Telemedicine Appointment – Privileges Only: a. Muhammad Masud, M.D. – Teleneurology

2. Leave of Absence:

a. Stephen Moenning, M.D. – General Surgery, 09-28-17 – 11-02-17 3. Resignation:

a. A. Catherine David, D.P.M. – Podiatry, effective 10-01-17 b. James Butler, D.O. – Cardiology, effective 09-28-17

4. Privilege Request:

a. Javier Alfonso, M.D. – Nephrology privileges 5. First Year Completions – Active Status:

a. Daniel Black, D.P.M. – Podiatry b. Amy Roth, D.O. – Internal Medicine c. Estela Thano, D.O. – Cardiology d. Steven Woodring, D.O. – Anesthesiology

6. First Year Completions – Associate Status:

a. Joseph Freedman, M.D. – Cardiology b. Nijal Sheth, M.D. – Nephrology

7. Allied Health Practitioners:

a. Leon Bard, PA – CCH ER Physicians b. Carrie Bauer, PA – Radiation Therapy Services c. Charles Crouse, CRNA – US Anesthesia Partners-FL d. Tilia Gonzalez, PA – Orthopedic Specialists of SW FL e. Laverne Jones, ARNP – LPG Neurology f. Melinda Rakesmith, CRNA – US Anesthesia Partners-FL g. Amber Ramsay Mason, CRNA – US Anesthesia Partners-FL h. Deborah Planes Whittington, ARNP – Florida Heart Associates i. Michelle Tolar, ARNP – LPG Cardiothoracic Surgery

Memorandum to Board of Directors - CCH October 18, 2017 Page 2 of 2









To: Board of Directors

From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services

Subject: Gulf Coast Medical Center Medical Staff Recommendations

Date: October 18, 2017

The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment: a. Peter Ameglio, M.D. – Orthopedic Surgery b. Oronzo Furio, M.D. – Internal Medicine c. David Gavin, D.P.M. – Podiatry d. Theresa Vensel, M.D. – Diagnostic Radiology


a. Muhammad Masud, M.D. – Teleneurology 3. Resignation:

a. A. Catherine David, D.P.M. – Podiatry, effective 10-01-17 b. James Butler, D.O. – Cardiology, effective 09-28-17


a. Daniel Black, D.P.M. – Podiatry b. Lynsey Biondi, M.D. – General Surgery c. Bernadette Ibitokun, M.D. – Internal Medicine d. Nijal Sheth, M.D. – Nephrology e. Patricia Villaflor, M.D. – Internal Medicine


a. Hanin Ayash, M.D. - Pediatrics b. Sharmila Tilak, M.D. – Internal Medicine


a. Carrie Bauer, PA – Radiation Therapy Services b. Tilia Gonzalez, PA – Orthopedic Specialists of SW FL c. Laverne Jones, ARNP – LPG Neurology d. Irene Julian, PA – GI Surgical Specialists e. Deborah Planes Whittington, ARNP – Florida Heart Associates f. Michelle Tolar, ARNP – LPG Cardiothoracic Surgery

Memorandum to Board of Directors - GCMC October 18, 2017 Page 2 of 2




8. Allied Health Practitioner – Intrasystem/Additional Sponsor:

a. Cynthia Edwards, CRNA – Anesthesia & Pain Consultants






To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Date: October 18, 2017 Subject: HealthPark Medical Center Medical Staff Recommendations The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment: a. Melanie Altizer, M.D. – OB/Gyn b. David Gavin, D.P.M. – Podiatry


a. Muhammad Masud, M.D. – Teleneurology 3. Change of Status:

a. Diana DeVall, M.D. – OB/Gyn, Honorary 10-01-17 4. Resignation:

a. A. Catherine David, D.P.M. – Podiatry, effective 10-01-17 b. James Butler, D.O. – Cardiology, effective 09-28-17 c. Frances Romero, M.D. – Family Medicine, effective 08-31-17

5. Privilege Request:

a. Michael DeFrain, M.D. – Thoracic Robotic Surgery b. Michael McCann, D.O. – General Surgery Robotic Surgery c. Moses Shieh, D.O. - General Surgery Robotic Surgery


a. Daniel Black, D.P.M. – Podiatry b. Nijal Sheth, M.D. – Nephrology c. Evans Valerie, M.D. – Pediatric General Surgery d. Steven Woodring, D.O. – Anesthesiology


a. Hanin Ayash, M.D. – Pediatrics b. Joseph Freedman, M.D. – Cardiology c. Sharmila Tilak, M.D. – Internal Medicine

Memorandum to Board of Directors - HPMC October 18, 2017 Page 2 of 2


8. Allied Health Practitioners: a. Carrie Bauer, PA – Radiation Therapy Services b. Ian Black, PA – LMHS ER Physicians c. Charles Crouse, CRNA – US Anesthesia Partners-FL d. Tilia Gonzalez, PA – Orthopedic Specialists of SW FL e. Robert Haynes, Jr., PA – LPG Trauma Surgeons f. Carolyn Howell, PA – LMHS ER Physicians g. Laverne Jones, ARNP – LPG Neurology h. Irene Julian, PA – GI Surgical Specialists i. Melinda Rakesmith, CRNA – US Anesthesia Partners-FL j. Amber Ramsay Mason, CRNA – US Anesthesia Partners-FL k. Deborah Planes Whittington, ARNP – Florida Heart Associates l. Michelle Tolar, ARNP – LPG Cardiothoracic Surgery








To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Date: October 18, 2017 Subject: Golisano Children’s Hospital of Southwest Florida

Medical Staff Recommendations The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment: a. Melanie Altizer, M.D. – OB/Gyn b. Siddika Mulchan, Psy.D. – Psychology c. Yasmin Mali, M.D. – Pediatric Ophthalomology

2. Change of Status:

a. Diana DeVall, M.D. – OB/Gyn, Honorary 10-01-17 3. First Year Completions – Active Status:

a. Evans Valerie, M.D. – Pediatric General Surgery b. Steven Woodring, D.O. – Anesthesiology


a. Hanin Ayash, M.D. – Pediatrics b. Emily Fall, D.M.D. – Pediatric Dentistry


a. Charles Crouse, CRNA – US Anesthesia Partners-FL b. Carolyn Howell, PA – LMHS ER Physicians c. Melinda Rakesmith, CRNA – US Anesthesia Partners-FL d. Amber Ramsay Mason, CRNA – US Anesthesia Partners-FL


____________________________________________ Sanford N. Cohen, M.D., Chairman - Board of Directors


OLD

BUSINESS


NEW

BUSINESS


BOARD OF DIRECTORS

BOARD MEETING CRITIQUE

Summary of Board Meeting Effectiveness Dashboard October 12, 2017

The Board Meeting Effectiveness Dashboard as completed by Board members at the meeting. The following information was taken from the Dashboard forms and shared with all Board members at the meeting.

Number of Responses 10/12/17

Red Yellow Green

Process Measure Did Not Meet Criteria

Mix of meets and did not meet

Consistently Meets Criteria

1. Effective Use of meeting time 5

2. Pre‐Meeting Materials distributed on time

5

3. Board Members stay on track 5

4. Presentation at Right level of detail

5

5. Effective Decision making process

1 4

6. Meeting Ends in Timely manner

1 4

What Needs Improvement (by Process Measure) 5. Effective Decision making process

Calling the question frequently causes confusion in the voting process Suggestions for Improvement or Observations (by Process Measure) 1. Effective Use of Meeting Time

Ability to understand other people’s votes

Avoid unnecessary explanation of items 4. Presentation at the right level of detail

Appreciated new template used for SNU report

5. Effective Decision making process

Consider only calling the question if discussion goes long not after only 2‐3 people speak

6. Meeting Ends in Timely Manner

Avoid unnecessary explanations of items

Next steps for improvement will be discussed at a future Board meeting.


BOARD OF DIRECTORS

BOARD OF DIRECTORS REPORTS


BOARD OF DIRECTORS

DATE OF THE NEXT REGULARLY SCHEDULED

MEETING:

FINANCE BOARD & FULL BOARD OF DIRECTORS MEETING

Thursday, November 9, 2017 1:00 p.m.

Gulf Coast Medical Center Boardroom, Suite 190

13685 Doctors Way Fort Myers, FL 33912