Board of Directors Meeting Thursday, April 30, 2020 1:00 p.m. · 2020-05-01 · Time Action 1.00...

Board of Directors Meeting

Thursday, April 30, 2020 1:00 p.m.

AGENDA BOARD OF DIRECTORS MEETING

April 30, 2020 AT 1:00 p.m. Electronic Meeting

Teleconference Call: Dial in # 1-415-655-0002 Conference Code: 479 841 169

Time Action 1.00 p.m. 1. Call to Order – David Collins, Board Chairman

The Board of Lee Memorial Health System, doing business as 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.

1.05 p.m. 2. Invocation & Pledge of Allegiance (Rabbi Dr. Michael Schorin, MAPC, BCC) 3. Public Input

1.10 p.m.

4. Consent Agenda a. Board Meeting Minutes of 3/26/2020 b. Board Special Meeting Minutes of 4/23/20 c. Medical Staff Credentialing d. Risk Management Report e. Designation of Administrator (Interim) and

Alternative Administrator for Lee Health Home Health

Approve

1.15 p.m. 5. President’s Report – (Larry Antonucci, President/CEO) Discuss

1.30 p.m. 6. Physician Leadership Council Update – (William Hearn, D.O., PLC Chairman) Discuss

1.45 p.m. 7. QSPE Report out (Therese Everly, Board Vice Chair, QSPE Committee Chair, Scott Nygaard, MD, Chief Operating Officer) Discuss

8. Board Meeting Evaluation 9. Adjourn

Date of the next Meeting: May 7, 2020 at 1.00 p.m.

Board of Directors Special Meeting Electronic Meeting

Teleconference Call: Dial in # 1-415-655-0002 Conference Code: Access code: 479 493 525

Lee Memorial Health System Board of Directors

BOARD OF DIRECTORS

Invocation &

Pledge of Allegiance

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BOARD OF DIRECTORS

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 should be completed and submitted to the Board Staff prior to meeting. Refer to Board Policy: 10:15H: 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

CONSENT AGENDA

a. Board Meeting Minutes of 3/26/20 b. Board Special Meeting Minutes of

4/23/20 c. Medical Staff Credentialing d. Risk Management Report e. Designation of Administrator (Interim)

and Alternative Administrator for Lee Health Home Health


BOARD OF DIRECTORS MEETING MINUTES

Thursday March 26, 2020

LOCATION: Teleconference dial in 209-5810 Conference Code 470 850 400 MEMBERS PRESENT: David Collins, Board Chair, Therese Everly, Board Vice Chair; Donna Clarke, Board Treasurer; Diane Champion, Board Secretary; Stephen Brown, M.D., Board

Member; Sanford N. Cohen, M.D., Board Member; Chris Hansen, Board Member; Stephanie Meyer, BSN, RN, Board Member; Nancy McGovern, RN, MSM, Board Member; Jessica Carter Peer, Board Member

MEMBERS ABSENT: None

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

David Collins welcomed everyone and asked the Board Members to announce their names for a roll call, by district number. He announced that all voting would also be conducted by roll call. Each Board Member verbally signified their presence and participation via telephonic communication.

FULL BOARD OF DIRECTORS MEETING was CALLED TO ORDER at 1:12 p.m.

by David Collins, Board Chair.

INVOCATION &

PLEDGE OF ALLEGIANCE

Chris Hansen Board Member gave the Invocation, followed by the Pledge of Allegiance.

PUBLIC INPUT Public input at the meeting was facilitated by electronic means. The method by

which the public could address the Board was published prior to the meeting. No requests to address the Board were received.

BOARD RESOLUTION David Collins asked for a motion to approve a board resolution providing for the operation of the Board during the Declared State of Emergency. Chair Collins asked George Knott, Board Counsel to address the proposed resolution. Jim Humphrey, Board Counsel, was present telephonically. George Knott reviewed the resolution for the Board’s consideration. Discussion ensued. A question was raised about the acceptability of electronic signatures. Board Counsel said that was acceptable. .

A motion was made by Therese Everly to suspend all Board policies and procedures during the duration of the public health emergency declared by Florida Governor, Ron DeSantis, in his Executive Orders 20-51 and 20-52, or until further resolution of the Board, whichever first occurs. The motion was seconded by Jessica Carter Peer and carried without opposition. A motion was made by Therese Everly to delegate to the Chairman of the Board of the Lee Health System the discretion to make, in consultation with Board Counsel, time sensitive decisions required of the Board of Directors if a quorum of the Board cannot be convened for an electronic special meeting in a timely fashion. Any decisions made pursuant to this delegation by the Chairman of the Board shall be promptly submitted to the full Board of Directors for its consideration and ratification at its next special or regular meeting at which a quorum can be established. This emergency delegation shall be for the duration of the public health emergency declared by Florida Governor, Ron DeSantis, in his Executive Orders 20-51 and 20-52, or until further resolution of the Board, whichever first occurs. The motion was seconded by Jessica Carter Peer and carried with no opposition.

CONSENT AGENDA David Collins asked for approval of the Consent Agenda.

A motion was made by Nancy McGovern to approve the Consent Agenda consisting of:

LEE HEALTH BOARD OF DIRECTORS MEETING MINUTES

Thursday, March 26, 2020



Due to a telephonic interruption, Sanford Cohen, M.D. was not available for the vote.

a. Board Meeting Minutes of 2/27/2020. The motion was seconded by Diane Champion and carried with no opposition.

MEDICAL STAFF CREDENTIALING

David Collins asked for approval of the Medical Staff Credentialing.

A motion was made by Therese Everly to approve the Medical Staff Credentialing. The motion was seconded by Stephen Brown, MD and carried with no opposition. Stephanie Meyer recused herself from the vote.

COMMITTEES’

SUMMARIES AND RECOMMENDATIONS

Donna Clarke, as Governance Committee Chair presented a verbal update of the committee meeting held on 3/12/20. Discussion ensued. Board Members asked for clarification of the motions on the consent agenda. Chris Hansen read the five motions on the Consent Agenda.

A motion was made by Donna Clarke to approve the recommendations of the Governance Committee as presented on the consent agenda consisting of: l. Policy Review

ll. Board Committee Assignments

i. Community Members ii. Physician Members

1. Community Health Improvement and Finance & Investment Committees

2. Quality, Safety & Patient Experience Committee The motion was seconded by Sanford Cohen, MD and carried with no opposition. Stephanie Meyer recused herself from the vote on Consent agenda item ll. ii Physician Members 2.QSPE Committee

PRESIDENT’S AND

PHYSICIAN LEADERSHIP COUNCIL

REPORT

Larry Antonucci, M.D. President / CEO and Bill Hearn, D.O., President / Physician Leadership Council, presented their reports with input from various Lee Health Senior Leaders on the Covid-19 pandemic. Discussion ensued with Board Members thanking both the Lee Health Leaders and Medical Staff for their leadership at this time.

RESOLUTION

AUTHORIZING DIRECT LOAN TO INCREASE

LIQUIDITY FOR COVID-19 FINANCIAL IMPACT

David Collins Board Chairman asked for a motion. Ben Spence presented the Board Resolution for consideration.

Motion was made by Nancy McGovern to request Board approval to adopt a resolution authorizing and approving a direct loan in the principal amount not to exceed $102,000,000 for the purpose of financing capital projects of the System and/or refinancing outstanding debt of the system; approving a form of loan agreement; authorizing the execution and delivery of documents and the taking of all other necessary actions in connection with the loan; providing for severability; and providing an effective date. The motion was seconded by Sanford Cohen, MD and passed with no opposition.

BOARD MEETING EVALUATION

The first teleconference was well received. Board Members expressed appreciation for all staff, physicians, and leadership during difficult time.


Thursday, March 26, 2020



NEXT REGULAR

MEETING The next LEE HEALTH

BOARD OF DIRECTORS MEETING will be held on April 30, 2020, at 1:00 p.m.

Teleconference Call: Dial In # 1-239-209-5810 Conference Code475 850 400

ADJOURNMENT The LEE HEALTH SYSTEM BOARD OF DIRECTORS MEETINGS

ADJOURNED at 3:55 p.m. by David Collins, Board Chair.

Minutes were recorded by Kathy J. Hagen / Assistant to the Board

______________________ __________________

Diane Champion, Date approved Board Secretary


BOARD OF DIRECTORS SPECIAL MEETING MINUTES

Thursday, April 23, 2020

LOCATION: Teleconference Number 1-415-655-0002, Access Code 479 493 525 MEMBERS PRESENT: Stephen Brown, M.D., Board Member; Donna Clarke, Board Treasurer; David Collins, Board Chair; Therese Everly, Board Vice Chair; Sanford N. Cohen, M.D., Board Member; Chris Hansen, Board Member; Stephanie Meyer, BSN, RN, Board Member; Diane Champion, Board Secretary; Nancy McGovern, RN, MSM,

Board Member; Jessica Carter Peer, Board Member MEMBERS ABSENT:

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.


MEETING CALLED TO ORDER

FULL BOARD OF DIRECTORS SPECIAL MEETING was CALLED TO ORDER at 1:00 p.m.

by David Collins, Board Chair.

INVOCATION AND

PLEDGE OF ALLEGIANCE

Michael Warthen M.Div., BCC gave the Invocation, followed by the Pledge of Allegiance.

PUBLIC INPUT None at this time.

BOARD SPECIAL

MEETING MINUTES David Collins, Chair asked for a motion to approve the Board Special Meeting Minutes dated 4/16/20.

Jessica Carter Peer made a motion to approve the Board Special Meeting Minutes dated 4/16/20 as presented. The motion was seconded by Chris Hansen and carried with no opposition

QUALITY, SAFETY &

PATIENT EXPERIENCE UPDATE

Scott Nygaard, M.D., Chief Operating Officer provided an update to the Board on the Surge Plan, Skilled Nursing Facilities (SNF), Skilled Nursing Unit (SNU) and the gradual reopening of future elective surgeries. Discussion ensued. He emphasized that the main factor limiting the resumption of services is the supply chain which affects the PPE needed both for COVID and non COVID treatment in our inpatient, outpatient and skilled nursing facilities. In addition, we are still under Governor DeSantis’ orders preventing elective surgeries. Larry Antonucci, CEO and President, reminded the Board that the Governor and his task force are working to develop plans to resume services while preserving public health and safety. He shared with the Board the Florida Hospital Association (FHA) “Open” recommendations. Observe the COVID-19 rate of occurrence in the community. Prevent transmission of COVID-19 to patients and health care providers. Establish a transparent and collaborative prioritization process to guide restoration of elective surgery and procedures. Network with all health care providers across the continuum of care to fully restore health care services.

PRESIDENT’S UPDATE

Larry Antonucci, CEO and President shared the April 22, 2020 Lee County COVID-19 confirmed positive cases graph data with the Board. He reported a slight increase in surgery rates due to previously needed surgeries now being deemed necessary. He also stated that there has been a 20-25% reduction in ER visits for strokes and heart attacks with no real decrease in these events occurring. He advised that a marketing campaign will address this situation.


Thursday April 23, 2020 Page 2 of 2


Minutes were recorded by Kathy J. Hagen / Assistant to the Board

______________________ __________________

Diane Champion, Date approved Board Secretary

Telemedicine continues to show a steady increase for the system still averaging in excess of 1000 visits per day. Lee Health is working with a potential new local supplier of masks, which is a significant need for the system. Lee Health continues to work closely with the local Department of Health and Lee County Councils to collate and provide timely accurate data for our community. Discussion ensued.

PLC REPORT UPDATE

Bill Hearn D.O., updated the Board on medical staff actions. He shared plans to survey PLC members on the efficacy of the meetings. The most recent meeting covered PPE proper fitting knowledge to eliminate waste, increase providing telemedicine use in hospitals and clarifying standards of care across facilities. Dr. Hearn stated they look forward to seeing what can be learned about the effective use of the telemedicine tool. He shared that medical staff are pleased with the degree at which campus level cooperation contributes to patient and staff safety. He also updated the Board on the surge plan and spoke about the medical staff perspective on the reopening of operations. He summed up their goal as a safe, responsible, judicious resumption of inpatient and outpatient services. He posed a question “can you open up too rapidly or too slowly”? Discussion ensued.

BOARD COUNSEL George Knott, Esq. reminded the Board members that Gov. DeSantis’ Executive Orders 20.69 allowing public governing bodies to conduct business electronically and 20.52 declared Public Health Emergency, are what allows our Board to operate via teleconference, and that those orders expire May 8, 2020. David Collins, Board Chair asked Board members to provide feedback on their views of the special meeting frequency as well as what to include in them after the May 7th meeting. Discussion ensued. Dr. Cohen asked Board Counsel if it is possible to write to the State’s General Counsel requesting an extension of Executive Order 20.69. Discussion ensued.

George Knott, Board Counsel will write to the State’s General counsel requesting an extension.

NEXT SPECIAL MEETING

The next LEE HEALTH BOARD OF DIRECTORS MEETING

will be held on April 30, 2020 at 1:00 p.m. Teleconference Number

1-415-655-0002 Access Code 479 841 169

ADJOURNMENT The LEE HEALTH SYSTEM

BOARD OF DIRECTORS MEETINGS ADJOURNED at 2:48 p.m.

by David Collins Board Chair.


Memorandum To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Date: April 22, 2020 Subject: Medical Staff Recommendations The Medical Executive Committees of the Medical Staff for Cape Coral Hospital, Golisano Children’s Hospital of Southwest Florida, Gulf Coast Medical Center, HealthPark Medical Center and Lee Memorial Hospital recommends the following physicians and advanced practice providers as set forth below and certifies they have met the requirements of the relevant facility Medical Staff Bylaws. ASSOCIATE STAFF APPOINTMENTS Myra Mercado, MD – Neonatology - CCH, GCHSWF, GCMC, HPMC, LMH Shapour Mirmanesh, M.D. – Internal Medicine - CCH, GCMC, HPMC, LMH Daren Spinelle, M.D. – Internal Medicine - CCH, GCMC, HPMC, LMH PRIVILEGES ONLY APPOINTMENTS Christopher Bixler, M.D. – Tele-Neurology - CCH, GCHSWF, GCMC, HPMC, LMH Sandro Corti, M.D. – Tele-Neurology - CCH, GCHSWF, GCMC, HPMC, LMH Rhona Holganza, M.D. – Pediatrics – GCHSWF Clifford Meyers, M.D. – Tele-Neurology - CCH, GCHSWF, GCMC, HPMC, LMH Luis R. Rodriguez, M.D. – Pediatrics – GCHSWF INTRASYSTEM APPLICATIONS Nattasha Acevedo-Ramirez, MD – Tele-Neurology - GCHSWF, HPMC, LMH Pierre Herard, MD – Physical Medicine & Rehab/Pain Management - CCH, GCMC Shikha Shrestha, MD – Internal Medicine (Refer & Follow) – GCMC, HPMC To provide coverage across the system due to COVID-19, Intrasystem requests have been obtained and processed for all the Emergency Physicians and Advanced Providers to have privileges at all facilities.

Cape Coral Emergency Physicians & APPs have requested GCMC, HPMC, and LMH SW Florida Emergency Physicians & APPs have requested CCH, HPMC, and LMH LMHS Emergency Physicians & APPs have requested CCH and GCMC

FIRST YEAR REVIEWS – see attached list PRIVILEGE REQUESTS Nattasha Acevedo-Ramirez, MD – Tele-Neurology from Neurology privileges Alexander Gumiroff, MD – GYN privileges - HPMC Greg Pound, DPM – Type I Podiatric privileges - CCH Shikha Shrestha, MD – Internal Medicine R&F from inpatient privileges TEMPORARY PRIVILEGES FOR NON-APPLICANTS Hassan Alkhatib, MD – Internal Medicine – CCH, GCMC, HPMC, LMH – 1st extension 3/23/20 – 4/21/20 2nd and final extension 4/22/20 – 5/21/20 Ann Imber, MD – Internal Medicine - CCH, GCMC, HPMC, LMH – 1st extension 4/11/20 – 5/10/20 2nd and final extension 5/11/20 – 6/9/20 Suprithi Ravi, MD – Internal Medicine – CCH, GCMC, HPMC, LMH –1st extension 4/4/20 – 5/3/20 2nd and final extension 5/4/20 – 6/2/20 LEAVE OF ABSENCE Norris Allen, MD – OB/GYN – GCMC, HPMC - Approved leave expired 4/1/20. no request for reinstatement. File will be closed Douglas Henricks, MD – Internal Medicine – GCMC, HPMC, LMH - Approved leave expires 5/1/20. Physician requested change to Honorary Michael Katin, MD – Radiation Oncology – CCH, GCMC, HPMC LMH - Approved leave expired 4/1/20. Physician requested reinstatement

Memorandum to Board of Directors April 22, 2020 - Page 2


RESIGNATIONS Resignation notifications have been received from the attached list of physicians ADVANCED PRACTICE PROVIDERS Heather Kenney, APRN – CCH, GCMC, HPMC, LMH – LPG Cardiology at Metro Katherine Leigh, PA – CCH, GCMC, HPMC, LMH – Florida Heart Associates Kristen Mason, APRN – CCH – LPG Associates in Cardiac Care Alexandra Phelps, APRN – HPMC, LMH – LPG General & Vascular Surgery Rachel Sims, APRN – CCH, GCMC – Florida Neurology Group Adelene Tolisano, APRN – CCH, GCMC, HPMC, LMH – Millennium Physician Group - Dr. Natalia Partain ADVANCED PRACTICE PROVIDERS – SPONSOR CHANGE Mary Demartini, APRN – HPMC, LMH – Lee Community Healthcare -–Dr. Leah Lynch CCH = Cape Coral Hospital GCMC = Gulf Coast Medical Center GCHSWF = Golisano Children’s Hospital of Southwest Florida HPMC = HealthPark Medical Center LMH = Lee Memorial Hospital Approved by the Board of Directors – April 30, 2020 ____________________________________________ David F. Collins, Chairman – Board of Directors

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: 04/30/2020 LEGAL SERVICE REVIEW? YES_X_ 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.

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. This request supports the following Strategic Initiative(s): Excellent Health Outcomes and Strong Financial Results

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

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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

January – March 2020

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.

1


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 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.

2


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 second quarter FY2020 was 3464


4

Reporting Rate (continued)


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

The graph for the fourth quarter indicates that 84.44% (2925) 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.

5


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

patient impact for the five facilities during the quarter.

6


CategoriesThis table shows the rate for the categories of reports from January through March 2020 at all five facilities. Rates per 1000 Patient Days are utilized to be consistent with other system reporting. 96% of all reports fall under the Patient Safety Taxonomy. The top five reports in this taxonomy are related to Care, IV Complications, Medication/Other Substance, Conduct, and Patient Falls.79% of all reported occurrences fall within one of these five categories

7During this quarter there were two adverse incident reported to AHCA

Taxonomy / Occurrence Type Total Rate PercentAdverse Drug Reaction 34 0.29 0.98%ADR, confirmed 13 0.11 0.38%ADR, suspected 21 0.18 0.61%HIPAA 14 0.12 0.40%LH - Patient Safety 3342 28.45 96.48%Conduct 429 3.65 12.38%Blood or Blood Product 31 0.26 0.89%Care 950 8.09 27.42%Device or Medical/Surgical Supply... 54 0.46 1.56%Environment 33 0.28 0.95%Fall 400 3.40 11.55%IV Complication 467 3.98 13.48%Laboratory 243 2.07 7.02%Medication or Other Substance 496 4.22 14.32%Other 6 0.05 0.17%Perinatal 73 0.62 2.11%Pressure Injury/Ulcer 14 0.12 0.40%Radiology 30 0.26 0.87%Surgery or Anesthesia 116 0.99 3.35%Security, Operation & Env. 53 0.45 1.53%Visitor Safety 21 0.18 0.61%Grand Total 3464 29.49


Safety Classification

8

Safety Event Class Occurrecne Type JAN FEB MAR Total RateNear Miss Behavior/AMA 1 0 0 1 0.01

Blood or Blood Product 6 3 5 14 0.12

Care 67 53 43 163 1.39

Device or Medical/Surgical Supply... 2 2 4 8 0.07

Environment 1 4 2 7 0.06

IV Complication 1 1 0 2 0.02

Laboratory 30 49 47 126 1.07

Medication or Other Substance 75 63 44 182 1.55

Other 0 0 1 1 0.01

Perinatal 0 2 0 2 0.02

Radiology 5 4 3 12 0.10

Surgery or Anesthesia 7 12 12 31 0.26

Near Miss Total 195 193 161 549 4.67

Precursor Blood or Blood Product 4 1 1 6 0.05Care 149 158 109 416 3.54Device or Medical/Surgical Supply... 9 8 2 19 0.16Environment 2 7 4 13 0.11Fall 7 2 4 13 0.11IV Complication 2 2 3 7 0.06Laboratory 26 43 18 87 0.74Medication or Other Substance 91 90 59 240 2.04Other 1 0 1 2 0.02Perinatal 3 1 1 5 0.04Pressure Injury/Ulcer 0 1 1 2 0.02Radiology 2 5 1 8 0.07Surgery or Anesthesia 5 6 0 11 0.09Precursor Total 301 324 204 829 7.06


LiabilityThe second fiscal quarter 2020 (January - March, 2020) ended with 43 pending claims. The quarter saw 7 claims closed and 13 claims opened. Malpractice prevention, patient safety and quality of care improvement continue to be the primary focus of the Health System’s risk managers.

9

0

5

10

15

20

25

30

35

40

45

50

FY18Q2 FY18Q3 FY18Q4 FY19Q1 FY19Q2 FY19Q3 FY19Q4 FY20Q1 FY20Q2

Num

ber o

f Cas

es

Number of Cases Linear (Number of Cases)


10

Risk Management Orientation for new hires Importance of Event Reporting for the Clinical Practice Council Documentation Inservice for Home Health Patient Safety Event Reporting Inservice Physician Inservice on Informed consent of Baker Acted Patients related to the

use of Psychotropic Medications Developed Physician Video Presentation related to Visitor/Family Interference in

Patient Care Nursing Risk Prevention During COVID-19 Pandemic for the Clinical Practice

council Patient Safety Inservice regarding Safe Transports for GCMC

Education Activities


11

Risk Management ActivitiesContinued participation in system patient safety activities including:

Clinical Practice Council Presentations System Medication Safety Committee Campus Specific Medication Safety Work Teams Participated in various Root and Apparent Cause Analysis

Teams Telemetry Leadership Team Executive Quality Safety Management Council Diversions Operations Committee Customer Improvement Team Magnant Preparation Clinical Practice Council Project – HandOff Communication Safe Care of Suicidal Patient Team Radiology Safety Council OB Safety Council Policy & Procedure Committee


Risk Management Goals

12

• 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

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: 4/30/2020 LEGAL SERVICE REVIEW? YES_X_ NO__ SUBJECT: Designation of Administrator (Interim) and Alternative Administrator for Lee Health Home Health REQUESTOR & TITLE: Kristine Fay, Chief Administrative Officer for Lee Physician Group, Home Health and Physician Services PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation) On February 14, 2019, the Lee Memorial Home Health, Inc. Board of Directors appointed Lisa Holt, PhD(c), MS, BSN as the Administrator and authorized Jonathan Hollander, RN, MBA, CPHQ, as alternate administrator for Home Health Services for Lee Memorial Home Health, Inc. effective January 7, 2019. SPECIFIC PROPOSED MOTION: Motion 1: To appoint Diane Smith, MS, RN, CMPE as the Administrator (Interim) for Home Health Services for Lee Memorial Home Health, Inc., effective April 12, 2020. Motion 2: To authorize Jonathan Hollander, RN, MBA, CPHQ, to act as an alternate administrator and assume the same responsibilities and obligations of the Administrator, when the Home Health Administrator is not available.

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 To comply with the CMS Conditions of Participation governing Home Health Services.

SUMMARY (including alternatives considered, Pros and Cons) Due to the recent resignation of Lisa Holt, we are requesting the Lee Memorial Home Health, Inc. Board of Directors appoint an interim Administrator. The CMS Conditions of Participation (42 C.F.R. 484.105) governing Home Health Services require the governing body to appoint the Administrator of the Home Health Agency. Further, the Conditions of Participation require the Administrator and the Governing Body to authorize, in writing, a qualified, pre-designated person, to assume the same duties and obligations as the administrator, when the administrator is not available. If appointed pursuant to Motion 1 above, Diane Smith, the Home Health Administrator (Interim), authorizes and recommends the Lee Memorial Home Health, Inc. Board of Directors authorize Jonathan Hollander to assume the same responsibilities and obligations of the Administrator, when the Home Health Administrator is not available.

mailto:[email protected]


BOARD OF DIRECTORS

PRESIDENT’S REPORT

Larry Antonucci, MD, President & CEO

1

Lee County COVID-19 Confirmed Positive Cases

The 14-day average for Lee County new confirmed cases is on a slight downward trend.Data Source: FL Dept. of Health – Data for 4/29 not available until 4/30 at 10:30am

2

Lee Health Testing


BOARD OF DIRECTORS

PHYSICIAN LEADERSHIP

COUNCIL UPDATE

William Hearn, D.O., PLC Chairman


BOARD OF DIRECTORS

QUALITY, SAFETY & PATIENT EXPERIENCE

REPORT

Therese Everly, Board Vice Chair, QSPE Committee Chair

Scott Nygaard, MD Chief Operating Officer

COVID-19 Update

QUALITY, SAFETY and PATIENT EXPERIENCE (QSPE) UpdateQSPE Administrative Sponsor:Scott Nygaard, MD, MBAChief Operating Officer

April 30, 2020

LEE HEALTH BOARD OF DIRECTORS

COVID-19Update

3

Lee County COVID-19 Confirmed Positive CasesData Source: FL Dept. of Health

The 14-day average for Lee County new confirmed cases is on a slight downward trend.

4

Tested Positive Patients Negative Patients

# Patients 6714 547 6165

% 8.1% 91.8%

91.8%

8.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1

Lee Health Testingcumulative totals as of 4/27/20

Positive Patients Negative Patients

Lee Health Testing

5

Lee Health Testing

The 14-day average for confirmed positive cases as a percentage of all patients tested is 6.9% and relatively flat. This measure definition is currently being refined.

QSPE System Update

PERFORMANCE OVERSIGHT

10

Board of Directors CMS 5 Star Dashboard

Domain Measure Performance Star RatingTimeline

Next update to BOD: 8/13/20

Exceptional Patient

Experience

Adult IP Patient Experience (HCAHPS)

Willingness to Recommend (% responses of 9 or 10)

[Owner: Sgarlata]

69.1% ** 3 Stars by end of FY2020

Medicare PE/DVT (PSI 12)[Owner: Daneshmand]

3.23 **** 5 Stars by Sept 2020

CAUTI SIR [Owner: Daneshmand]

0.264 ***** 4-5 Stars by June 2020

CLABSI SIR [Owner: Daneshmand]

0.471 ****Execute on action plans to improve 4 Stars by

Sept 2020

SSI-Colon Surgery SIR[Owner: Daneshmand]

0.371 **** 4-5 Stars by Sept 2020

MRSA SIR[Owner: Daneshmand]

0.741 *** 4 Stars by Sept 2020

CDIFF SIR[Owner: Daneshmand]

0.343 **** 5 Stars by June 2020

Medicare Readm-30-All Cause[Owner: Kole/Millette] 13.91% **** 2-3 Stars by Sept 2020

Notes: HCAHPS,CAUTI, CLABSI, C.Diff, MRSA, PE/DVT (FY20-Mar),SSI-Colo (FY20-Feb) , 30-Day Readm (FY20-March 24th)

Excellent Health

Outcomes

Patient Impact Composite Measures

11

Medicare

PE/DVT (PSI 12)[Owner: Daneshmand]

CAUTI SIR [Owner: Daneshmand]

CLABSI SIR [Owner: Daneshmand]

SSI-Colon Surgery

SIR[Owner: Daneshmand]

MRSA SIR[Owner: Daneshmand]

CDIFF SIR[Owner: Daneshmand]

3.23 0.264 0.471 0.371 0.741 0.343

**** ***** **** **** *** ****

Patient Impact Composite Measures

Updated Frequency: Pending official update to Star Rating methodology, next release will occur in 2021.

Performance periods: Mortality: : 3Q15-2Q18 Readmission: 3Q15-2Q18 (Cond); Q17-2Q18(Hospital-Wide)Safety: HAs (1Q18-4Q18) ; PSI90 (3Q16-2Q18); COMP-HIP-KNEE (2Q15-1Q18)

Patient Experience: (1Q18-4Q18) Efficient Use of Medical Imaging: (3Q172Q18)Timeliness: (1Q18-4Q18)Effectiveness of Care: (1Q18-4Q18)

Update Frequency: April & OctoberData Source: LeapFrog

Current Leapfrog Grades Fall 2019

FYTD 20 SYSTEM STRATEGIC SCORECARD UPDATE

16

HCAHPS Likelihood to Recommend: National 72%; State 70%-- as of March 2019

Exceptional Patient Experience

Strategic Pillars Annual Objectives

Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current

Status Tracking Reporting Period

RIGHT CULTURE

86.6% 75.8% 78.4% 69.1%

90th 54th 63rd 32nd

80.9% 69.5% 72.4% 67.0%

90th 60th 70th 50th

Exceptional

Patient

Experience

Does not

MeetFYTD Mar

Does not

MeetFYTD Mar

Patient Experience (Adult Acute IP HCAHPS Recommend)

Patient Access(Adult LPG Access Perception)

Higher is

Better

Higher is

Better

Right Care

17


Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current


RIGHT CARE

45 137 107 133

90th 74th 80th 75th

1.53% 1.53% <1.53% 1.51%

90th 90th >90th >90th

5,075 FYTD Mar

10,150 Annualized FY 20

Excellent Health

Outcomes

Better

than GoalFYTD Mar

Increase the LPG Primary

Care Patient Base--

Higher is

Better11,000 12,000

Does not

Meet

Patient Impact(National Healthcare Safety Network nursing units,

NHSN)

Lower is

Better

Meets

GoalFYTD Feb

Mortality(Lee Health facilities only)

Lower is

Better

Patient Impact by Condition

18

Coordinated Care Model

19


Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current


RIGHT TIME & PLACE

13.47% 14.32% 13.47% 13.91%

90th 50th 90th 78th

13.6% 14.60% 14.10% 15.67%

90th 70th 80th 48th

Meets

GoalFYTD Mar 22

Does not

MeetFYTD Mar

Coordinated Care

ModelAdult IP Ambulatory Care

Sensitive Condition Rate

Lower is

Better

Medicare Payor 30-day

Readmission Rate

(Lee Health facilities only/Qlik-Epic)

Lower is

Better

Right Cost

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Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current


RIGHT COST

FYTD Mar

Better

than GoalFYTD Mar

Strong Financial

Results Operating Margin % 4.7%Higher is

Better3.0% 3.5% 2.5%

Does not

Meet

Year over year freestanding outpatient

revenue growth

(2019 vs 2020)--

Higher is

Better11.0% 15.0% 19.2%

READMISSIONS UPDATE

Lee Health Performance Excellence Team

23

Annual Operating Objectives: Meeting Target

Target Performance: Actual Performance:

Exceeding Target Meeting Target CURRENT METRIC: 13.91 % readmission rate for CMS all payor- FYTD 14.8 % CMS Bundle readmission rate in Jan–Mar versus 17.20 % for Jan-Mar 201913.47% (90th percentile) 14.32% (50th percentile)

What was your Last Step? * How do you know its happening?

CURRENT DETAILED APPROACH: CMS Bundle Physician Leaders focused on readmissions through outpatient

access/Collaboration with Nurse navigators Working closely with Cardiac Care Transition clinic for appointments Sharing Physician specific performance with LPG Medical Directors Shared new Cedar gate Technology data with Bundle Physician leaders EMS to include 30 day readmission column on run sheet live July 1st in EPIC

ACCOUNTABILITY MECHANISM:

CMS Bundle specific KPI Scorecard Weekly tracking of Nurse navigator and Social Work activities Innovatus Call Hub validating all patients lists pre and post discharge

What Obstacles are you experiencing? Which ONE are you addressing & How can we help?

TOP 2-3 OBSTACLES / BARRIERS

Follow up appointments post discharge remains inconsistent High readmission rates from Skilled Nursing facilities & Home Health Reducing readmissions in Emergency Departments is not a top strategy

COUNTERMEASURE FOR TOP OBSTACLE & SUPPORT NEEDED FROM SLC: Nurse navigators making specialty appointments and verifying completion Improve % of appointments at discharge and verify completion of appointment Engage all Emergency Departments in reducing readmissions program Redesign Home Health to be a close partner with Innovatus Health to reduce readmissions

What is your Next Step? *To be noted in next Metric Update When can we expect to see results?

NEXT ACTION IN APPROACH: Increasing access for Pulmonary/Cardiology/Infectious Disease practices Increase Nurse Navigation for moderate-high risk pts to coordinate care Increase chronic disease education Inpatient/Outpatient

NEXT PREDICTED MILESTONE ACHEIVEMENT ACCORDING TO PLAN: Reduction in bundle readmissions starting in CY 2nd quarter as Innovatus Health Nurse

navigator program expands to coordinate care in the post acute environment

Strategic Objective:

Executive Owner:

TITLE: Reducing Readmissions

NAME: Lisa Sgarlata & Marilyn Kole

CMS Bundle: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Sepsis

EXCEPTIONALLEE PATIENT EXPERIENCE AND ENGAGEMENT

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System Strategic Scorecard FY2020Right Culture


Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current


RIGHT CULTURE

86.6% 75.8% 78.4% 69.1%

90th 54th 63rd 32nd

80.9% 69.5% 72.4% 67.0%

90th 60th 70th 50th

Exceptional

Patient

Experience

Does not

MeetFYTD Mar

Does not

MeetFYTD Mar

Patient Experience (Adult Acute IP HCAHPS Recommend)

Patient Access(Adult LPG Access Perception)

Higher is

Better

Higher is

Better

Rec’d Target: 75.8% (54th %-ile)

Annual Operating Objectives: NOT Meeting Target

Target Performance: Actual Performance:

Exceeding Target Meeting Target Likelihood to recommend Exceeds+ Nurse Communication Physician Communication -April Care Transitions Responsiveness of Staff

78.4%/ 63rd%tile 75.8%/54th%tile

What was your Last Step? * How do you know its happening?

• Continue with accountability with NLR which includes the VPs rounding once a month with the nurse leader.

• PX Specialist at each campus round with each nurse leader at least once a week to continue with coaching, reward and recognition.

ACCOUNTABILITY:• VPs are to initial on the hospital dashboard they have rounded. • VPs are to report to Scott and share their dashboard during their monthly 1:1

What Obstacles are you experiencing? Which ONE are you addressing & How can we help?

• Competing priorities, i.e.; expansion, season, holding of IPs in ED• Inconsistent use of facility dashboards and unit huddle boards• VPs not consistently rounding with nurse leaders on routine basis; results in nurse

leader perceiving NLR is not a priority.• Inconsistent skills and behaviors of NLR among nurse leaders

• CipherHealth placed on hold during COVID response

Top Areas of Focus and support:• Need help with accountability. Cipher Health with help with this.• VPs held accountable to round with each nurse leader once a month and validate that

with Scott.• Consistent support from VPs at each campus to hold nurse leaders accountable for the

practice and behavior of NLR- facility dashboards and huddle boards.• Mandatory NLR training for CCH and LMH nurse leaders.

What is your Next Step? *To be noted in next Metric Update When can we expect to see results?

Next 90 days focus on Nurse-leader Rounding and identifying with each nursing unit that EBP which will make the biggest impact: Bedside shift report; review the plan of care with the patient; intentional rounding.

With a consistent 90 day focus, LHS will meet the fiscal year goal of 75.8%*Reevaluation of 90 day focus post-COVID – specifically maintaining the use of technology used during our acute phase for communication with family and education.

Strategic Objective:

Executive Owner:

Date:

TITLE: Patient Experience Adult IP HCAHPS “Likelihood to Recommend”

NAME: Lisa Sgarlata

DATE: April 24, 2020

28

Obstacles

Competing priorities

Inconsistent us of facility dashboards and unit huddle boards

Consistency of rounding with nurse leaders on a routine basis; results in nurse leader perceiving nurse-leader rounding is not a priority

Inconsistent skills and behaviors of nurse-leader rounding amongst nurse leaders

29

Top Areas of Focus and Support

Accountability:

Senior Leadership and Dyads to round with nurse leaders

Consistent support for the practice and behaviors of nurse-leader rounding in regards to facility dashboards and huddle boards

Mandatory training for leaders of units with greatest opportunity for improvement

Strategy for 2020

30

Strategic Focus: Next 90 days

Continued focus on nurse-leader rounding and identifying with each nursing unit that evidence-based practice will make the biggest impact: Bedside shift report; Review of the Plan of Care with the Patient; Intentional Rounding

Implement “Commit to Sit” for our physicians as requested

Development of comprehensive strategies for our hospitalists around patient experience

SAFETY EVENT UPDATE AND TRENDS

Good Catches vs Precursor Events

More than 200% Increase in Ambulatory

32

Overall Lee Health Reporting Trend

Overall Safety Trends

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.

33

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Rolling 12 Month Serious Safety Event RateEVENTS SSER

SSE System Bench Mark: 0.06 SSER / 10,000 Adjusted Patient Days

Year to Date: 0.0927 SSER / 10,000 Adjusted Patient Days

6 SSEs / 647,406 Adjusted Patient Days

0

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24 Month Serious Safety Event RateEVENTS SSER

FLORIDA STERLING SITE VISITFEEDBACK REPORT

Florida Sterling Site Visit

35

LEAPFROG SPRING 2020 PROJECTIONS & OPPORTUNITIES

37

Predicted Leapfrog Safety GradesLeapfrog Safety Grades for April 2020 are predicted to remain above the “A” cutoff.*National A thresholds assumed to remain stable based on historical cutoffs.

38

Predicted Leapfrog Safety Grades

Leapfrog Safety Grades for April 2020 are predicted to remain above the “A” cutoff *National A thresholds assumed to remain stable based on historical cutoffs.

39


40


BOARD MEETING EVALUATION

ADJOURNMENT

DATE OF THE NEXT

BOARD OF DIRECTORS SPECIAL MEETING

May 7, 2020 1:00 P.M.

Dial in Conference Number 1-415-655-0002

Attendee Access Code 479 493 525

Board of Directors Meeting Thursday, April 30, 2020 1:00 p.m. · 2020-05-01 · Time Action 1.00...

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