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Lee Memorial Health System Board of Directors
Quality, Safety & Education and Full Board
of Directors Meetings
Thursday, October 26, 2017 1:00 p.m.
Lee Memorial Health System Board of Directors
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
Lee Memorial Health System Board of Directors
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)
Lee Memorial Health System Board of Directors
BOARD OF DIRECTORS
Invocation &
Pledge of Allegiance
Lee Memorial Health System Board of Directors
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.
Lee Memorial Health System Board of Directors
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
Lee Memorial Health System Board of Directors
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
Lee Memorial Health System Board of Directors
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
3
4
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
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Clostridium difficile(C diff)
Clostridium Difficile WorkgroupStuart Paasche, P.A., Co‐ChairHolly Muller, RN, VP, PCS Co‐ Chair
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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
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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
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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
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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
Marcelo Zottolo, MS, System Director, Process Analytics
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
Marcelo Zottolo, MS, System Director, Process Analytics
K. Alex Daneshmand, DO, Acute Care Medical Officer/Patient Safety Officer
What is Leapfrog’s Hospital Safety Grade?
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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
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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
Marcelo Zottolo, MS, System Director, Process Analytics
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)
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)
SameNational Avg (3 star)
Below National Avg (1‐2 Star)
Above National Avg (5 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
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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
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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
34% acceptance (35/102) since 5/17
Body Mass Index In Production April 2016
Offers selection of problems when missing
Elevated BMI 58% acceptance (5809/9940) since 4/16
Anemia In ProductionJune 2017
Offers selection of problems when missing
Transfusion order for PRBC
71% acceptance (501/710) since 6/17
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
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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
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35
Safety Perception
36
Safety Perception
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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
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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
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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
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Safety Communication2
Education ModuleTo Become Safety Coaches
New Recognition Badges
Standardize Our Safety Coaches Participation
Closing the loop of Communication
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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
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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
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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
• 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
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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.
Marcelo Zottolo, MS, System Director, Process Analytics
Page 70Page 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)
Page 71
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
Page 72
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 73Page 73
Event Rate Target (0.06) Event Rate Target (0.06)
Event Rate Target (0.06) Event Rate Target (0.06)
Page 74Page 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 76Page 76
Page 77Page 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 78Page 78
Page 79Page 79
Page 80Page 80
Page 81Page 81
Page 82Page 82
Page 83Page 83
Page 84Page 84
Page 85
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
50%-ileFY 2019 VBP Domain Weighting Report Stephen Streed
Qtr 2 FY 2017(Mar-17)
X X
SYSTEM ACUTE CARE - HAI CLOSTRIDIUM DIFFICILE INFECTIONS (C. DIFF.)SIR = 0.924
50%-ileSIR = 0.924
50%-ileFY 2019 VBP Domain Weighting Report Stephen Streed
Qtr 2 FY 2017(Mar-17)
X X
SYSTEM ACUTE CARE - HAI COLORECTAL SURGICAL SITE INFECTIONS (SSIs)SIR = 0.783
50%-ileSIR = 0.783
50%-ileFY 2019 VBP Domain Weighting Report Stephen Streed
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
LEE MEMORIAL HOSPITAL
“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
Chaplain, Cape Coral Hospital
June 7, 2017
12:15 p.m. – 1:15 p.m. Rev. Denise Sawyer, MDiv, BCC
Chaplain, Cape Coral Hospital
April 18, 2017
12:30 p.m. – 1:30 p.m. Rev. Denise Sawyer, MDiv, BCC
Chaplain, Cape Coral Hospital
LECTURE TITLES
CAPE CORAL HOSPTAL
GOLISANO CHILDREN’S
HOSPITAL OF SOUTHWEST FLORIDA
GULF COAST MEDICAL
CENTER
HEALTHPARK MEDICAL
CENTER
LEE MEMORIAL HOSPITAL
“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
12:00 p.m. – 1:00 p.m. Rev. Denise Sawyer, MDiv, BCC
Chaplain, Cape Coral Hospital
“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
LOCATION/GROUP DATE ATTENDANCE
GCH PEDS ETHICS CONSULT 11/23/16 MEMBERS 5
ATTENDANCE TOTALS GUESTS 0
MEMBERS: 13 5/24/17 MEMBERS 8
GUESTS: 0 GUESTS 0
LOCATION/GROUP DATE ATTENDANCE
GCMC – ETHICS CONSULT 12/14/16 MEMBERS 10
GUESTS 1
ATTENDANCE TOTALS 3/8/17 MEMBERS 5
MEMBERS: 23 GUESTS 1
GUESTS: 4 6/14/17 MEMBERS 8
GUESTS 2
LOCATION/GROUP DATE TOTAL
HPMC ETHICS CONSULT 11/30/16 MEMBERS 6
GUESTS 1
ATTENDANCE TOTALS 6/7/17 MEMBERS 6
MEMBERS: 12 GUESTS 2
GUESTS: 3 12/6/17 MEMBERS
TBD GUESTS
LOCATION/GROUP DATE ATTENDANCE
LMH ETHICS CONSULT 1/7/17 MEMBERS 4
GUESTS 1
ATTENDANCE TOTALS 4/18/17 MEMBERS 3
MEMBERS: 11 GUESTS 1
GUESTS: 2 7/18/17 MEMBERS 4
GUESTS 0
LOCATION/GROUP DATE ATTENDANCE
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)
Lee Memorial Health System Board of Directors
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
Lee Memorial Health System Board of Directors
SUBJECT DISCUSSION ACTION FOLLOW-UP
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
Lee Memorial Health System Board of Directors
SUBJECT DISCUSSION ACTION FOLLOW-UP
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.
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
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 WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
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
2The 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 WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
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
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.
0
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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)
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
4The 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.
Reporting Rate (continued)
0
10
20
30
40
50
Rate per 100
0 Pa
tient Days
HealthPark Medical Center
HPMC Linear (HPMC)
0
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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
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50
Rate per 100
0 Pa
tient Days
Lee Memorial Hospital
LMH Linear (LMH)
0
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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)
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
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.
5The 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.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percent of reports without im
pact
LMHS Linear (LMHS)
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
AnalysisThis graph reflects the reporting rate per 1000 patient days and the rate of
patient impact for the four facilities during the quarter.
6
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.
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
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
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
7The 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.
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
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
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
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
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
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
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.
10The 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.
0
5
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15
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25
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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)
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
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.
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.
PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM
Thank You
Lee Memorial Health System Board of Directors
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 Memorial Health System Board of Directors
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
Lee Memorial Health System Board of Directors
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
Lee Memorial Health System Board of Directors
LEE HEALTH Lee County, Florida
#2 M E M O R A N D U M
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
Lee Memorial Health System Board of Directors
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
Lee Memorial Health System Board of Directors
LEE HEALTH Lee County, Florida
#3 M E M O R A N D U M
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
2. Telemedicine Appointment – Privileges Only:
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
4. First Year Completions – Active Status:
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
5. First Year Completions – Associate Status:
a. Hanin Ayash, M.D. - Pediatrics b. Sharmila Tilak, M.D. – Internal Medicine
6. Allied Health Practitioners:
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
Lee Memorial Health System Board of Directors
7. Allied Health Practitioner – Sponsor Change:
a. Melinda Cole, ARNP – Heart & Vascular Institute b. Amy Riddle, ARNP – Heart & Vascular Institute
8. Allied Health Practitioner – Intrasystem/Additional Sponsor:
a. Cynthia Edwards, CRNA – Anesthesia & Pain Consultants
Approved by the Board of Directors – October 26, 2017
________________________________________________ Sanford N. Cohen, M.D., Chairman - Board of Directors
Lee Memorial Health System Board of Directors
LEE HEALTH Lee County, Florida
#4 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: 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
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. 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
6. First Year Completions – Active Status:
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
7. First Year Completions – Associate Status:
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
Lee Memorial Health System Board of Directors
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
9. 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
Lee Memorial Health System Board of Directors
LEE HEALTH Lee County, Florida
#5 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: 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
4. First Year Completions – Associate Status:
a. Hanin Ayash, M.D. – Pediatrics b. Emily Fall, D.M.D. – Pediatric Dentistry
5. Allied Health Practitioners:
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
Approved by the Board of Directors – October 26, 2017
____________________________________________ Sanford N. Cohen, M.D., Chairman - Board of Directors
Lee Memorial Health System Board of Directors
OLD
BUSINESS
Lee Memorial Health System Board of Directors
NEW
BUSINESS
Lee Memorial Health System Board of Directors
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.
Lee Memorial Health System Board of Directors
BOARD OF DIRECTORS
BOARD OF DIRECTORS REPORTS
Lee Memorial Health System Board of Directors
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